Three-field Lymphadenectomy Research Articles

Obstructive shock and cardiac arrest due to diaphragmatic hernia after esophageal surgery: a case report.

We report the exceedingly rare case of diaphragmatic hernia after esophageal surgery resulting in obstructive shock and cardiac arrest. An 82-year-old man, who had undergone a robotic-assisted thoracoscopic esophagectomy and gastric tube reconstruction via a subcutaneously route with three-field lymphadenectomy for esophagogastric junction cancer at another hospital 3months prior, complaining of persistent epigastric pain and nausea. Computed tomography revealed that the proximal jejunum had herniated through the esophageal hiatus into the left thoracic cavity, with dilation of the subcutaneous gastric tube and duodenum. He was urgently admitted, and a nasogastric tube was inserted. His respiratory and circulatory parameters were normal upon admission, however, nine hours after admission, there was a rapid increase in oxygen demand, and he subsequently developed shock. His blood pressure was 106/65 mmHg, pulse rate of 150bpm, respiratory rate of 30/min with an O2 saturation of 97% on High-flow nasal cannula FiO2:0.4, cyanosis and peripheral coldness appeared. Chest X-ray showed a severe mediastinal shift to the right, suggesting obstructive shock due to intestinal hernia into the thoracic cavity. Emergency surgery was planned, but shortly after endotracheal intubation, the patient experienced cardiac arrest. It was found that approximately 220 cm of small intestine had herniated into the thoracic cavity through the esophageal hiatus, and it was being strangulated by the diaphragmatic crura. A portion of the diaphragmatic crura was incised to manually reduce the herniated small intestine back into the abdominal cavity. The strangulated intestine was congested, but improvement in coloration was observed and it had not become necrotic. The procedure finished with closure of the esophageal hiatus. Intensive care was continued, but he died on postoperative day 29 because of complications including perforation of the descending colon and aspiration pneumonia. Rapid progression of small intestine hernia into the thoracic cavity, leading to obstructive shock, was suspected. While this case was rare, early recognition of the condition and prompt reduction could have potentially led to life-saving outcomes.

776. THREE-FIELD LYMPHADENECTOMY IN ESOPHAGEAL CANCER: EXPERIENCE OF A PORTUGUESE TERTIARY CENTER

Abstract Background The American Joint Committee for Cancer (AJCC) and the Japanese Esophagus Society (JES) differ in the N classification for esophageal cancer, with the former considering the presence of disease in the supraclavicular lymph nodes as M1, and the latter classifying it as loco-regional disease in thoracic esophageal tumors. Patients who would be excluded from a curative intent treatment strategy by the AJCC classification may be candidates for surgery with lymphadenectomy of nodal groups 101 and 104 (JES). Our goal is to understand the impact of three-field lymphadenectomy on morbidity, loco-regional control and overall survival in patients with esophageal cancer. Methods A retrospective cohort study was conducted using data from a prospective database from a single center, which included all consecutive patients undergoing esophagectomy for cancer with either two-field total thoracic lymphadenectomy or three-field lymphadenectomy, between January 2019 and December 2023. Three-field lymphadenectomy was performed for clinical supraclavicular and recurrent nerve nodal involvement and for proximal third tumors. We assessed the morbidity and mortality of both types of surgery, and loco-regional and distant recurrence and overall survival for both groups. Results Of the 279 esophagectomies for cancer, 137 were included for analysis. The median age was 65 years, with 84% males. 58,4% had squamous cell carcinoma and 41,6% adenocarcinoma. 34.3% of the patients had a 3-field lymphadenectomy, 27,7% of these for supraclavicular N+ and 34% for recurrent nerve N+. Conclusion In this large single-center cohort, patients with significant lymph node involvement, treated with esophagectomy and three-field lymphadenectomy, demonstrated comparable loco-regional control and overall survival to more favorable cases, with no statistically significant increase in morbidity and mortality.

510. INNOVATIVE ROBOTIC-ASSISTED ESOPHAGECTOMY WITH THREE-FIELD LYMPHADENECTOMY: A NOVEL APPROACH TO ESOPHAGEAL CANCER SURGERY

Abstract Background Esophageal squamous cell carcinoma, the predominant form of esophageal cancer in Thailand, often presents at advanced stages (III - IV), necessitating surgical intervention. Radical esophagectomy, including three-field lymphadenectomy, stands as one of the most invasive gastrointestinal surgeries. However, in the era of minimally invasive surgery (MIS), robotic systems have emerged as a formidable approach to achieve radical treatment goals while minimizing surgical invasiveness. This video showcases a novel surgical technique and its challenges. Methods A case of mid-thoracic esophageal squamous cell carcinoma, clinically staged III, treated via robotic-assisted esophagectomy and three-field lymphadenectomy using the Da Vinci Xi system. The operation encompassed three phases: Initially, the thoracic phase with patient in semi-prone position with three robotic and one assistant trocars for complete esophageal mobilization and mediastinal lymph node retrieval. The abdominal phase, followed by the cervical phase, utilized four robotic trocars and one assistant trocar in supine position with hyperextended neck, facilitating perigastric lymph node retrieval, gastric tube reconstruction via the posterior mediastinal route, and cervical esophago-gastric tube anastomosis using a circular stapler. Results The patient experienced an uneventful recovery. Postoperative esophagogastroduodenoscopy on day 1 revealed the integrity of the anastomosis and normal vocal cord function. Imaging conducted on day 7 confirmed that the anastomosis was patent without any leakage. Surgical outcomes included an operative time of 615 minutes, estimated blood loss of 150 ml, a 14-day hospital stay, and recovery without complications. This video highlights the intricacies of the procedure and the robotic system's ability to access anatomically challenging spaces, thereby minimizing surgical invasiveness and enhancing recovery. Conclusion The robotic system is capable of performing radical procedures in anatomically challenging areas, such as narrow spaces and areas requiring precise maneuverability among vital structures. It enables a comprehensive approach spanning from the upper to the lower thoracic regions and diversity of surgery in thoracic and abdominal cavity. Additionally, this presentation highlights unique surgical tips and techniques that enhance the safety and feasibility of robotic-assisted esophagectomy. By significantly reducing surgical errors and optimizing outcomes for both oncologic and minimally invasive surgeries, it thereby marks a significant leap forward in the field of esophageal surgery. https://drive.google.com/file/d/1vrmu2D8TGoetnplcREPWQocXJle4PrOX/view?usp=share_link

237. THE PROGNOSTIC VALUE OF NODAL SKIP METASTASIS IN PATIENTS WITH ESOPHAGEAL CANCER

Abstract Background Nodal skip metastasis (NSM), a common form of lymphatic spread in esophageal cancer (EC), refers to metastatic involvement of distant lymph nodes (LNs) without prior engagement of adjacent LNs. Previous studies examining the association between NSM and survival outcomes in EC patients have yielded inconsistent and even contradictory results. This systematic review and meta-analysis aim to assess the prognostic value of NSM and summarize NSM definitions used in prior studies. Methods Four databases were employed for this meta-analysis. The relationship between NSM and overall survival (OS) was assessed using pooled hazard ratios (HRs) and their 95% confidence intervals (CIs). Sensitivity analysis and funnel plots were utilized to evaluate publication bias. Results This meta-analysis incorporated nine studies, and the pooled results revealed no significant association between NSM and OS (HR = 0.99, 95% CI: 0.75–1.31; P = 0.951). Sub-group analyses based on histological features, method of lymphadenectomy, node staging system, and NSM definitions also failed to identify a significant association between NSM and OS. Conclusions Based on the available evidence, NSM cannot be considered a prognostic factor for EC patients. Future studies examining the prognostic value of NSM should focus on employing three-field lymphadenectomy with an adequate number of harvested LNs. NSM definitions based on lymph node station and anatomical compartment could both serve as feasible classifications for EC.

Short-term outcomes of three- and two-field lymphadenectomy with minimally invasive esophagectomy for esophageal cancer: a propensity score-matching analysis.

Whether patients can benefit from three-field lymphadenectomy (3-FL) in minimally invasive esophagectomy (MIE) remains unclear. This study retrospectively compared short-term outcomes between 3-FL and two-field lymphadenectomy (2-FL) in MIE for patients with esophageal cancer (EC) and aimed to evaluate the clinical significance of 3-FL. There were 284 patients enrolled in the study (124 patients with 3-FL and 160 patients with 2-FL). The cases were matched based on their propensity scores using a matching ratio of 1:1, the nearest neighbor matching protocol, and a caliper of 0.02. Patients were propensity-score matched for sex, cancer location, Age-adjusted Charlson Comorbidity Index (ACCI), and neoadjuvant treatment. The short-term outcomes were postoperative complications, operation characteristics, pathology results and postoperative hospital stay. There were no significant differences in intraoperative hemorrhage, postoperative hospital stay, or postoperative complications between the 2-FL and 3-FL groups. The operation time of the two groups was significantly different (227.1±46.2 vs. 248.5±45.9 min, P=0.001); the operation time of the 3-FL group was about 20 minutes longer than that of the 2-FL group. The number of lymphatic nodes (LNs) obtained in the 3-FL group was significantly higher than that in the 2-FL group (31.3±12.9 vs. 54.6±18.0, P<0.001). Pathological N stage was also significantly different (P=0.002); the 3-FL group was more advanced than the 2-FL group. Compared to 2-FL MIE, 3-FL MIE does not increase postoperative complications, can obtain more LNs, and improves the accuracy of tumor LN staging.

Mapping of lymph node metastasis from esophageal squamous cell carcinoma after neoadjuvant treatment: a prospective analysis from a high-volume institution in China.

The study aimed to describe the prevalence of lymph node metastases per lymph node station for esophageal squamous cell carcinoma (ESCC) after neoadjuvant treatment. Clinicopathological variables of ESCC patients were retrieved from the prospective database of the Surgical Esophageal Cancer Patient Registry in West China Hospital, Sichuan University. A two-field lymphadenectomy was routinely performed, and an extensive three-field lymphadenectomy was performed if cervical lymph node metastasis was suspected. According to AJCC/UICC 8, lymph node stations were investigated separately. The number of patients with metastatic lymph nodes divided by those who underwent lymph node dissection at that station was used to define the percentage of patients with lymph node metastases. Data are also separately analyzed according to the pathological response of the primary tumor, neoadjuvant treatment regimens, pretreatment tumor length, and tumor location. Between January 2019 and March 2023, 623 patients who underwent neoadjuvant therapy followed by transthoracic esophagectomy were enrolled. Lymph node metastases were found in 212 patients (34.0%) and most frequently seen in lymph nodes along the right recurrent nerve (10.1%, 58/575), paracardial station (11.4%, 67/587), and lymph nodes along the left gastric artery (10.9%, 65/597). For patients with pretreatment tumor length of >4cm and non-pathological complete response of the primary tumor, the metastatic rate of the right lower cervical paratracheal lymph nodes is 10.9% (10/92) and 10.6% (11/104), respectively. For patients with an upper thoracic tumor, metastatic lymph nodes were most frequently seen along the right recurrent nerve (14.2%, 8/56). For patients with a middle thoracic tumor, metastatic lymph nodes were most commonly seen in the right lower cervical paratracheal lymph nodes (10.3%, 8/78), paracardial lymph nodes (10.2%, 29/285), and lymph nodes along the left gastric artery (10.4%, 30/289). For patients with a lower thoracic tumor, metastatic lymph nodes were most frequently seen in the paracardial station (14.2%, 35/247) and lymph nodes along the left gastric artery (13.1%, 33/252). The study precisely determined the distribution of lymph node metastases in ESCC after neoadjuvant treatment, which may help to optimize the extent of lymphadenectomy in the surgical management of ESCC patients after neoadjuvant therapy.

Standardization and short-term outcomes of robot-assisted minimally invasive esophagectomy in the semi-prone position

Robot-assisted minimally invasive esophagectomy (RAMIE) has recently been developed and is increasingly performed for thoracic esophageal and esophagogastric junction (EGJ) cancers. At our institute, we performed RAMIE in the semi-prone position using the da Vinci Xi system with two- or three-field lymphadenectomy in 91 patients with resectable thoracic esophageal or EGJ cancers between October 2018 and March 2023. During this period, we improved and standardized the surgical procedures to perform precise and safe mediastinal lymphadenectomies and minimize postoperative complications. The rates of major operative morbidities (C-D grade, ≥ I) were acceptable (recurrent laryngeal nerve paralysis, 6.6%; pneumonia, 9.9%; atelectasis, 6.7%; anastomotic leak, 14.3%). Both operative and 30-day mortality rates were 0%. In this technical note, we present our standardized surgical techniques for RAMIE in the semi-prone position for esophageal and EGJ cancers.

Risk factors and prognosis for supraclavicular lymph node metastasis in patients with thoracic esophageal cancer. Distant or regional metastasis?

We aimed to determine the frequency and prognosis of supraclavicular (#104) lymph node (LN) metastasis compared with other LN stations in patients with advanced thoracic esophageal cancer and to identify risk factors for metastasis to delineate the indications for three-field lymphadenectomy (3FL). The study cohort of 567 eligible patients with esophageal cancer had undergone subtotal esophagectomy from 2003 to 2020. LN metastasis was defined as pathologically proven metastasis or positron emission tomography-positive LNs. The efficacy index (EI), calculated from the frequency of LN metastases and survival rates, was used as prognostic value of each LN station dissection for patient survival. Risk factors for #104 LN metastasis were determined by multivariable logistic regression. The frequency of #104 LN metastasis was 11.6% overall, 31.7% in upper and 8.3% in middle/lower third lesion. Neoadjuvant chemotherapy was administered to 71% of patients and chemo-radiation to 11%. The 5-year overall survival was 45.8%. The EI for #104 LNs (5.3) was similar to that for #101 LNs. Risk factors were age < 65years, upper third lesion, clinical N2-3, #101/106rec LN metastasis and poorly differentiated carcinoma. The 5-year overall survival of patients with middle/lower lesions was 38% (EI 3.1), similar to that for #101 and #8/9/11 LNs. The prognosis of patients with #104 LN metastases is similar to that of patients with metastases in other regional LN stations. Therefore, we recommend 3FL exclusively for patients at a high risk of #104 LN metastasis due to the overall metastatic rate not being high.

216. SHORT-TERM OUTCOMES OF 111 CASES OF MEDIASTINOSCOPIC ESOPHAGECTOMY FOR ALL ESOPHAGEAL CANCERS

Abstract Background Mediastinoscopic esophagectomy (ME) as a radical surgery for esophageal cancer is considered promising because of its low complication rate of pneumonia. In our hospital, ME with three-field lymphadenectomy is the first choice for radical esophagectomy and is indicated for all cases of esophageal cancer, including borderline resectable, locally invasive tumors, conversion surgery, and salvage surgery. However, there have been few reports of ME for highly advanced esophageal cancer, and its safety and feasibility are unknown. Methods From April 2018 to April 2023, we retrospectively investigated all cases of radical esophagectomy at our hospital. Patient characteristics and perioperative short-term outcomes were investigated. Results cStage 0/I/II/III/IV were 7/20/26/37/21 respectively. 70% of patients were treated with neoadjuvant chemotherapy. ME was performed in 111 cases, thoracoscopy and thoracotomy in 0 cases. The conversion rate from ME to thoracotomy was 0.9%. The mean operation time was 547 min and blood loss was 215 mL. Postoperative complications of classified as grade II in the CD classification occurred in 19.8%, and more than grade IIIa occurred in 13.5%. The mean postoperative hospital stay was 20 days. The number of dissected lymph nodes was 47. The completion rate of R0 surgery was 94%. Conclusion ME for all esophageal cancers, including borderline resectable tumors and locally invasive tumors, was safe and feasible. ME with three-field lymphadenectomy may be the first choice for radical esophagectomy.

258. A VIDEO-UPDATE OF THE LEARNING CURVE OF THE INTRODUCTION OF MINIMALLY INVASIVE TRANSCERVICAL ESOPHAGECTOMY (MICE)

Abstract Background A radical esophagectomy is considered the cornerstone of a curative treatment strategy for esophageal cancer. However, transthoracic approaches are associated with high morbidity rates, even in expert centers. Pulmonary complications and anastomotic leakage are the most frequent and have the most impact. In the pursuit to improve clinical outcomes for patients with esophageal cancer, reducing post-operative complications is essential. Methods Minimally Invasive trans-Cervical Esophagectomy (MICE) is an innovative surgical technique, combining a single-port trans-cervical mediastinal dissection with a laparoscopic transhiatal esophagectomy. This approach facilitates a radical esophagectomy and a two- or three-field lymphadenectomy, while avoiding a thoracoscopy/thoracotomy. Therefore, MICE could reduce pulmonary complications and the consequences of anastomotic leakage, without compromising oncological radicality. Reducing post-operative complications will impact mortality, quality of life, long-term survival, and costs. Results The first MICE procedure in a Dutch esophageal cancer patient was performed at Radboudumc in January 2021, after an extensive pre-clinical trajectory. Subsequently a prospective pilot study was conducted in 20 consecutive patients undergoing MICE. The primary outcome, pulmonary complication rate, was 15% (3/20), which is substantially lower than after transthoracic minimally invasive esophagectomy (TMIE). Recurrent laryngeal nerve palsy (RLNP) occurred in seven (35%) cases, of which six recovered spontaneously, and this is in concordance with the results of Japanese series. Anastomotic leakage occurred in 15% of patients, which is in similar to our national benchmark of 18%. Conclusion We would like to share one of our latest surgical videos of MICE during our learning curve. Probably this will be around consecutive case number 70.

430. MAPPING OF LYMPH NODE METASTASIS FROM ESCC AFTER NEOADJUVANT TREATMENT: A PROSPECTIVE ANALYSIS FROM A HIGH-VOLUME INSTITUTION IN CHINA

Abstract Objective The aim of the study was to describe the prevalence of lymph node metastases per lymph node station for esophageal squamous cell carcinoma (ESCC) after neoadjuvant treatment. Methods Clinicopathological variables of ESCC patients were retrieved from the prospective database of the Surgical Esophageal Cancer Patient Registry in West China Hospital, Sichuan University. Two-field lymphadenectomy was routinely performed and an extensive three-field lymphadenectomy was performed if cervical lymph nodes metastasis were suspected. Lymph node stations according to AJCC 8 were separately investigated. Percentage of patients with lymph node metastases was defined as number of patients with metastatic lymph nodes/number of patients with lymph node dissection of this station. Data is also separately analyzed according to pathological response of the primary tumor, pretreatment tumor length and tumor location. Results Between January 2019 and March 2023, 623 patients who underwent neoadjuvant therapy followed by transthoracic esophagectomy were enrolled (Table 1–1). Lymph node metastases were found in 215 patients (34.5%) and most frequently seen in lymph nodes along the right recurrent nerve (10.1%, 58/575), paracardial station (11.4%, 67/587) and lymph nodes along the left gastric artery (10.9%, 65/597). For patients with pretreatment tumor length &amp;gt; 4 cm and non-PCR of primary tumor, the metastatic rate of right lower cervical paratracheal lymph nodes is 10.9% (10/92) and 10.6% (11/104), respectively (Table 1–2). For patients with an upper thoracic tumor, metastatic lymph nodes were most frequently seen along the right recurrent nerve (14.2%, 8/56). For patients with a middle thoracic tumor, metastatic lymph nodes were most frequently seen in the right lower cervical paratracheal lymph nodes (10.3%, 8/78), paracardial lymph nodes (10.2%, 29/285) and lymph nodes along the left gastric artery (10.4%, 30/289). For patients with a lower thoracic tumor, metastatic lymph nodes were most frequently seen in paracardial station (14.2%, 35/247) and lymph nodes along the left gastric artery (13.1%, 33/252) (Table 1–3). Conclusion The study accurately identified the distribution of lymph node metastases from ESCC after neoadjuvant treatment, which may contribute to guide the optimal extent of lymphadenectomy in the surgical treatment of ESCC patients after neoadjuvant treatment.

Trends in Lymphadenectomy for Esophageal/Esophagogastric Junction Cancer

Lymph node (LN) metastasis is recognized to be an important prognostic factor for esophageal cancer (EC). However, there is no worldwide uniform classification system, and no consensus exists on the extent of the lymphadenectomy. Recently, an international observational cohort study was conducted to evaluate the distribution of LN metastasis in EC patients. Moreover, this could be a milestone to establish a standard classification system and provide new insights to determine the extent of LNs that should be target for treatment. With regard to surgical procedures, three-field lymphadenectomy seems to be promising to improve the prognosis with EC patients. However, extended lymphadenectomy could lead to postoperative complications. The development of minimally invasive esophagectomy (MIE) has allowed us to retrieve cervical paraesophageal nodes without cervical incision and reduce the incidence of postoperative complications. Therefore, it may be possible that the era of MIE could propose the modern extent of LN dissection in the future. Additionally, one of the key components in lymphadenectomy for EC was thoracic duct and surrounding tissues. Although there is some evidence of LN metastasis surrounding the TD, the survival benefit of TD resection is still debatable. With regard to esophagogastiric junction cancer, the extent of LN dissection could be determined by the length of esophageal involvement. We believe further understanding of LN metastasis of EC patients will contribute to establish a global standard of treatment and improve their prognosis.

Hotspots and prospects of esophageal cancer research in China

Esophageal cancer is a malignant tumor with a high incidence in China. At pesent, advanced esophageal cancer patients are still frequently encountered. The primary treatment for resectable advanced esophageal cancer is surgery-based multimodality therapy, including preoperative neoadjuvant therapy, such as chemotherapy, chemoradiotherapy or chemotherapy plus immunotherapy, followed by radical esophagectomy with thoraco-abdominal two-field or cervico-thoraco-abdominal three-field lymphadenectomy via minimally invasive approach or thoracotomy. In addition, adjuvant chemotherapy, radiotherapy, or chemoradiotherapy, or immunotherapy may also be administered if suggested by postoperative pathological results. Although the treatment outcome of esophageal cancer has improved significantly in China, many clinical issues remain controversial. In this article, we summarize the current hotspots and important issues of esophageal cancer in China, including prevention and early diagnosis, treatment selection for early esophageal cancer, surgical approach selection, lymphadenectomy method, preoperative neoadjuvant therapy, postoperative adjuvant therapy, and nutritional support treatment.

Impact of two‑field or three‑field lymphadenectomy on overall survival in middle and lower thoracic esophageal squamous cell carcinoma: A single‑center retrospective analysis.

Squamous cell carcinoma is the main subtype of esophageal cancer in East Asia. The effect of the number of lymph nodes (LNs) removed to treat middle and lower thoracic esophageal squamous cell carcinoma (ESCC) in China remains controversial. Therefore, the present study aimed to investigate the impact of the number of LNs removed during lymphadenectomy on the survival of patients with middle and lower thoracic ESCC. Data were obtained from the Sichuan Cancer Hospital and Institute Esophageal Cancer Case Management Database from January 2010 to April 2020. Either three-field systematic lymphadenectomy (3F group) or two-field systematic lymphadenectomy (2F group) was performed for ESCC cases with or without suspicious tumor-positive cervical LNs, respectively. Subgroups were designed for further analysis based on the quartile number of resected LNs. After 50.7 months of median follow-up, 1,659 patients who underwent esophagectomy were enrolled. The median overall survival (OS) of the 2F and 3F groups was 50.0 months and 58.5 months, respectively. The OS rates at 1, 3 and 5 years were 86, 57 and 47%, respectively, in the 2F group, and 83, 52 and 47%, respectively, in the 3F group (P=0.732). The average OS of the 3F B and D groups was 57.7 months and 30.2 months, respectively (P=0.006). In the 2F group, the OS between subgroups was not significantly different. In conclusion, resection of >15 LNs during two-field dissection in patients with ESCC undergoing esophagectomy did not affect their survival outcomes. In three-field lymphadenectomy, the extent of LNs removed could lead to different survival outcomes.

ASO Visual Abstract: Safety and Feasibility of Robot-Assisted Minimally Invasive Esophagectomy (RAMIE) with Three-Field Lymphadenectomy and Neoadjuvant Chemoradiotherapy in Patients with Resectable Esophageal Cancer and Cervical Lymph Node Metastasis.

ASO Visual Abstract: Safety and Feasibility of Robot-Assisted Minimally Invasive Esophagectomy (RAMIE) with Three-Field Lymphadenectomy and Neoadjuvant Chemoradiotherapy in Patients with Resectable Esophageal Cancer and Cervical Lymph Node Metastasis.

Pattern of relapse following three-field lymphadenectomy of esophageal carcinoma and related factors predictive of recurrence

PurposeFor treatment of esophageal carcinoma, the optimal postoperative radiotherapy target volume after three-field lymph node dissection (3-FLD) had not been determined. We analyzed local recurrence pattern of thoracic esophageal carcinoma and risk factors of lymph node recurrence after 3-FLD without prophylactic radiotherapy. Material and methodsWe reviewed 1282 patients with thoracic esophageal squamous cell carcinoma (ESCC) who were treated with 3-FLD without radiotherapy from 2010 to 2018 and analysed local recurrence patterns and risk factors of lymph node recurrence, in order to provide a reference for determination of the radiotherapy target volume for thoracic ESCC. ResultsThe lymph node recurrence accounted for 91.0% of treatment failures. The mediastinal, cervical and abdominal lymph node recurrence accounted for 84.92%, 36.07% and 22.30%, respectively (χ2=264.776, P=0.000). The superior, middle and inferior mediastinal lymph node recurrence rates were 67.54%, 27.87% and 0.98%, respectively (χ2=313.600, P=0.000). Cervical metastases were significantly associated with N stage and Preoperative cervical lymph node status. Abdominal metastases were significantly associated with the number of preoperative abdominal lymph node metastases (LNM), tumor location and N stage. ConclusionsThe main pattern of local-regional recurrence might be lymph node metastasis after radical 3-FLD without radiotherapy in esophageal carcinoma. The dangerous lymph node recurrence regions included neck, superior and middle mediastinum. The abdominal areas might be irradiated for lower TEC patients with preoperative abdominal LNM.

Safety and Feasibility of Robot-Assisted Minimally Invasive Esophagectomy (RAMIE) with Three-Field Lymphadenectomy and Neoadjuvant Chemoradiotherapy in Patients with Resectable Esophageal Cancer and Cervical Lymph Node Metastasis.

In the West, patients with cervical lymph node metastasis of resectable esophageal cancer at diagnosis are generally precluded from curative treatment. This study prospectively explored the safety and feasibility of neoadjuvant chemoradiotherapy followed by robot-assisted minimally invasive esophagectomy (RAMIE) with three-field lymphadenectomy for these patients. Between 2015 and 2021, patients with resectable thoracic esophageal cancer and cervical lymph node metastasis were recruited nationwide in the Netherlands. Patients without interval metastasis following neoadjuvant chemoradiotherapy and good physical condition underwent RAMIE with bilateral three-field lymphadenectomy. Safety was predefined as ≤50% Clavien-Dindo grade ≥3b postoperative complications. Neoadjuvant chemoradiotherapy was administered to 29 patients (19 (66%) adenocarcinoma and 10 (34%) squamous cell carcinoma). After restaging, nine (31%) patients were excluded (interval metastasis, clinical deterioration, or withdrawn consent). RAMIE was performed in 20 patients (R0-rate 95%). A median of 42 [range 21-71] lymph nodes were resected of which 13 [range 2-35] were cervical. Only 1 (5%) patient had an unexpected contralateral cervical lymph node metastasis. Complications grade ≥3b occurred in 50%. Most frequent complications of any grade were recurrent laryngeal nerve palsy (45%) and pneumonia (40%). Overall survival at 1 year was 85% and quality of life at 6 months was comparable to esophageal cancer patients treated with curative intent. RAMIE with three-field lymphadenectomy following neoadjuvant chemoradiotherapy for patients with resectable esophageal cancer presenting with cervical lymph node metastasis is feasible in a Western population. Because contralateral cervical metastasis is rare, a unilateral neck dissection would suffice in the majority of cases. gov Identifier: NCT02426879. Dutch trial register Identifier: NTR 4552.

Significance of lymphovascular invasion in esophageal squamous cell carcinoma undergoing neoadjuvant chemotherapy followed by esophagectomy.

Lymphovascular invasion (LVI) was previously reported to be an independent factor associated with survival in locally advanced esophageal squamous cell carcinoma (LAESCC) patients receiving neoadjuvant chemotherapy (NAC); however, the detailed clinicopathological significance of LVI remains unclear. This study evaluated the prognostic impact of LVI in patients with LAESCC after NAC with cisplatin and 5-fluorouracil (CF) or docetaxel, cisplatin and 5-fluorouracil (DCF) followed by surgery and in LAESCC patients with recurrence after NAC and surgery. 438 patients with thoracic LAESCC who had undergone NAC followed by an esophagectomy with three-field lymphadenectomy were assessed using a propensity score matched analysis, and their long-term outcomes were retrospectively reviewed. In matched cohort, a multivariate analysis of relapse-free survival (RFS) in the NAC-CF group suggested that ypN (≥ 1, HR = 3.715, p = 0.004) and LVI (positive, HR = 3.366, p = 0.012) were independent factors associated with RFS; in the NAC-DCF group, ypN (≥ 1, HR = 4.829, p < 0.001) was the only independent factor associated with RFS. Comparisons of overall survival (OS) between the ypN + /LVI + group and other groups among patients with recurrence in each NAC regimen showed significant differences in both of NAC groups (p < 0.001, respectively). The ypN + /LVI + group had a significantly poor OS in both an oligometastatic recurrence (OMR) group (p < 0.001) and a non-OMR group (p < 0.001). The present study suggested that the independent factor associated with prognosis of patients with LAESCC after NAC and surgery may differ according to the NAC regimen, and the presence of both ypN and LVI was a prognostic factor for patients with recurrence, including those with OMR. These results might be helpful when deciding on an additional treatment strategy for LAESCC patients.

The Prognostic Value of Nodal Skip Metastasis in Patients with Esophageal Cancer: A Systematic Review and Meta-Analysis.

Esophageal cancer (EC) is the sixth leading cause of cancer deaths worldwide. Nodal skip metastasis (NSM), a common form of lymphatic spread in EC, can be defined as the metastatic involvement of distant lymph nodes (LNs) without prior involvement of adjacent LNs. The results of the previous studies investigating the association between NSM and survival outcomes in patients with EC were inconsistent and even contradictory. The aim of this systematic review and meta-analysis is to investigate the prognostic value of NSM and to summarize the NSM definitions of EC in previous studies. Four databases were used in this meta-analysis. The association between NSM and overall survival (OS) was evaluated by using pooled HRs and their 95% confidence interval (CI). The sensitivity analysis and funnel plot were used to assess the publication bias. Nine studies were included in this meta-analysis. The pooled results of meta-analysis indicated that there was no significant association between NSM and OS (HR = 0.99, 95% CI: 0.75-1.31; P = 0.951). Meanwhile, according to the results of sub-group analysis on the basis of histological feature, method of lymphadenectomy, node staging system, and NSM definitions, no significant association was found between NSM and OS. On the basis of available evidences, NSM could not be used as a prognostic factor for patients with EC. For future studies investigating the prognostic value of NSM, only three-field lymphadenectomy with adequate harvested LNs can be performed. NSM definitions based on lymph node station and anatomical compartment could both be feasible classification for EC.

Editorial acerca de “Esofagectomía con linfadenectomía guiada por fluorescencia con verde de indocianina en cáncer de esófago“

Esophageal cancer is one of the gastrointestinal cancers with the greatest incidence over the past years and is the eighth most common cancer worldwide, affecting more than 450 000 people per year1. Its treatment and prognosis depend on tumor stage, location, histological type, nutritional status and presence of comorbidities2. Although there have been significant advances in the field of oncology in recent years, esophagectomy with lymph node clearance remains the main curative treatment. Total esophagectomy with two-field or three-field lymphadenectomy plays a very important role in the locoregional control of the disease. In recent years, the technological advances and the development of minimally invasive surgical techniques have significantly reduced morbidity and mortality.