Response to Dr Pramesh and co-authors

Abstract

We thank Dr CS Pramesh and co-authors for their comments which we read with huge interest. Several arguments are given here to respond to their questions. We agree with the fact that a significant percentage of supracarinal lymph nodes are involved in oesophageal cancer, the reason why our educational article suggests a radical transthoracic oesophagectomy, with supracarcinal, but not cervical, lymph node dissection. 1 Mariette C. Piessen G. Oesophageal cancer: how radical should surgery be?. Eur J Surg Oncol. 2012; 38: 210-213 Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar With regard to cervical lymphadenectomy, many arguments are given in our article against the systematic use of a three-field lymphadenectomy. Of course those assertions are based on the current literature and we recognize that more evidence is needed. Consequently, the randomised trial promoted by the authors testing the safety and the survival impact of a three-filed lymphadenectomy would be of huge help. As described in our paper, 1 Mariette C. Piessen G. Oesophageal cancer: how radical should surgery be?. Eur J Surg Oncol. 2012; 38: 210-213 Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar the literature supports a three-field lymphadenectomy for subgroups of patients in whom the balance between benefits and risks is beneficial. We hope that the authors' trial will help to further identify which patients may benefit from a three-field, rather than a two-field, radical lymphadenectomy. Moreover, we agree that the higher the number of lymph nodes retrieved the better the locoregional control and the survival, 2 Peyre C.G. Hagen J.A. DeMeester S.R. et al. The number of lymph nodes removed predicts survival in esophageal cancer: an international study on the impact of extent of surgical resection. Ann Surg. 2008; 248: 549-556 Crossref PubMed Scopus (172) Google Scholar but this can also be achieved with a radical two-field lymphadenectomy. 3 Mariette C. Piessen G. Briez N. Triboulet J.P. The number of metastatic lymph nodes and the ratio between metastatic and examined lymph nodes are independent prognostic factors in esophageal cancer regardless of neoadjuvant chemoradiation or lymphadenectomy extent. Ann Surg. 2008; 247: 365-371 Crossref PubMed Scopus (307) Google Scholar The quality of the lymphadenectomy in the abdominal and the thoracic compartments is probably of greater significance than the absolute number of nodes removed, as demonstrated by the “en bloc” concept. 3 Mariette C. Piessen G. Briez N. Triboulet J.P. The number of metastatic lymph nodes and the ratio between metastatic and examined lymph nodes are independent prognostic factors in esophageal cancer regardless of neoadjuvant chemoradiation or lymphadenectomy extent. Ann Surg. 2008; 247: 365-371 Crossref PubMed Scopus (307) Google Scholar In other words, the number of nodes removed is not by itself the absolute paragon, but rather one of several controls of surgical quality. Finally, as reported by the authors, acceptable rates of postoperative morbidity and mortality after three-field lymphadenectomy are achievable in experienced hands but need to be proven in common practice, especially in the obese patients more and more frequently observed in Western countries.