Abstract
We thank Dr Shetty and colleagues [1Shetty P.S. Sawant A. Mankar H. Pramesh C.S. Extent of lymphadenectomy in operable esophageal cancer (letter).Ann Thorac Surg. 2017; 104: 375Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar] for their comments on our article “Total lymphadenectomy and nodes-based prognostic factors in surgical intervention for esophageal adenocarcinoma” [2Ruffato A. Lugaresi M. Mattioli B. et al.Total lymphadenectomy and nodes-based prognostic factors in surgical intervention for esophageal adenocarcinoma.Ann Thorac Surg. 2016; 101: 1915-1920Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. We agree that the number of yielded lymph nodes is not an optimal benchmark for esophagectomy because it may be influenced by the technique of node retrieval, and that it would be better to predefine the groups of lymph nodes to remove than to resect nodes in stations where metastases may be rare or null. We disagree when they propose the adoption of a lymphadenectomy “efficacy index” according to the position of the primary tumor, distinguished according to the upper esophagus, the middle esophagus, or the lower esophagus, in which adenocarcinoma is included [3Udagawa H. Ueno M. Shinohara H. et al.The importance of grouping of lymph node stations and rationale of three-field lymphoadenectomy for thoracic esophageal cancer.J Surg Oncol. 2012; 106: 742-747Crossref PubMed Scopus (124) Google Scholar]. In fact, the 7th edition of the American Joint Committee on Cancer TNM staging system [4Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, eds. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Verlag; 2009.Google Scholar], in the chapter on esophageal cancer, includes two different staging forms, squamous cell carcinoma and adenocarcinoma histologic types; adenocarcinoma of the esophagus, cardia, and proximal stomach infiltrating the cardia were unified in the adenocarcinoma staging form. The 7th TNM has produced simplification but also controversies [5Mattioli S. Ruffato A. Di Simone M.P. et al.Immunopathological patterns of the stomach in adenocarcinoma of the esophagus, cardia, and gastric antrum: gastric profiles in Siewert type I and II tumors.Ann Thorac Surg. 2007; 83: 1814-1819Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 6Ruffato A. Mattioli S. Perrone O. et al.Esophagogastric metaplasia relates to nodal metastases in adenocarcinoma of esophagus and cardia.Ann Thorac Surg. 2013; 95: 1147-1153Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. In a study with histologic and immunochemical parameters, we determined that the esophageal adenocarcinoma family is composed of three entities: a Barrett’s-type pattern, a gastric cancer–like pattern, and a third entity that is distinct from the other two [5Mattioli S. Ruffato A. Di Simone M.P. et al.Immunopathological patterns of the stomach in adenocarcinoma of the esophagus, cardia, and gastric antrum: gastric profiles in Siewert type I and II tumors.Ann Thorac Surg. 2007; 83: 1814-1819Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar]. Successively, we showed that in the three subgroups, the frequencies of lymphatic metastases in the thoracic and abdominal stations are significantly different [6Ruffato A. Mattioli S. Perrone O. et al.Esophagogastric metaplasia relates to nodal metastases in adenocarcinoma of esophagus and cardia.Ann Thorac Surg. 2013; 95: 1147-1153Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. In our vision, future research on esophageal cancer will focus on subgroups characterized by biologic patterns that will replace prognostic indicators like the surgery-driven TNM system (the premise for personalized medicine); surgeons will switch from “Big Data” clinical research to numerically limited studies based on adequate-quality surgical treatment and the biologic characterization of each case. Extent of Lymphadenectomy in Operable Esophageal CancerThe Annals of Thoracic SurgeryVol. 104Issue 1PreviewWe read with interest the recent article [1] evaluating the extent to which benchmarks for optimum lymphadenectomy during esophagectomy are followed and the ideal prognostic variable for long-term outcomes after esophagectomy. We agree with the authors that while benchmarks might be useful as a general measure of quality, these are dependent on multiple factors that are difficult to standardize. We believe that the following factors influence the total number of lymph nodes reported on histopathologic analysis: whether the nodes are individually dissected by the operating surgeon or during specimen grossing by the pathologist, whether neoadjuvant treatment was used, expertise of the operating surgeon, fragmentation of nodes especially during thoraco-laparoscopic esophagectomy, and the diligence of the pathologist. Full-Text PDF
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