Two-field Dissection Research Articles

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.

Short-term outcomes after conventional transthoracic esophagectomy.

In our department, we have attempted to reduce the incidence of complications of conventional esophagectomy. The objective of this retrospective study was to report the short-term outcomes of esophagectomy. We reviewed 138 consecutive patients who had undergone subtotal esophagectomy by combined laparotomy via a 12-cm upper abdominal vertical incision combined with right anterior muscle-sparing thoracotomy from August 2010 to August 2014. Most of the cervical para-esophageal lymph node dissection was completed within the thoracic cavity. We performed three-field dissection in patients with tumors in the upper or middle third of the esophagus with clinical lymph node metastases in the superior mediastinum; the others underwent two-field dissection. We performed neck anastomoses in patients undergoing three-field dissection and thoracic anastomoses in those undergoing two-field dissection. Effective postoperative pain management was achieved with a combination of epidural anesthesia and paravertebral block. Postoperative rehabilitation was instituted for early ambulation and recovery. Enteral nutrition via a duodenal feeding tube was administered from postoperative day 2. Median hospital stay after surgery was 15 days (range, 10-129). Rates for both 30-day and in-hospital mortality were 0%. Morbidity rate for all Clavien-Dindo grades was 41.3%, whereas the morbidity rate for Clavien-Dindo grades III and IV was 7.2%. Anastomotic leakage developed in two patients (1.4%), recurrent laryngeal nerve palsy in 11 (8.0%), and pneumonia in nine (6.5%). Good short-term outcomes, especially regarding anastomotic leaks, were achieved by consistent improvements in surgical techniques, optimization of several operative procedures, and appropriate perioperative management.

Minimally invasive esophagectomy combined with super-extended two-field lymph node dissection for squamous cell esophageal carcinoma：early results

Objective To assess the safety and early oncologic results of minimally invasive esophagectomy(MIE)combined with super-extended two-field lymph node dissection for treating esophageal squamous cell carcinoma.Methods A total of 49patients who underwent MIE through McKeown approach(right chest,left neck,and abdomen)between May 2012and Dec.2013were enrolled in this study.Lymph node dissection fields included whole mediastinum,lower para-esophagus viathoracoscope route,and abdomen.Results The patients included 44males and 5females,with an age range of 45-78years old and a median of 58years old.Sixteen(32.7%)patients were at StageⅠ.Forty-eight(98.0%)patients received complete resection,and 18(36.7%)patients had post-operation complications,including 9(18.4%)with neck leakage and 7(14.3%)with vocal cord paralysis.Post-operative early death occurred in one case.The mean number of removed lymph nodes was 18and the lymph node metastasis rate was 42.9%(21/49);28.6%(6/21)of the positive nodes were found in the upper mediastinum and lower para-esophagus areas.Seven of the 18patients who were followed up had recurrence,with a recurrent rate of 38.9%.The 7cases included 5in the locoregional areas and 2in distant organs.Conclusion MIE combined with super two-field dissection can achieve the lymphadenectomy effect recommended by National Comprehensive Cancer Network(NCCN),with satisfactory safety.Short-term follow-up indicates that the locoregional recurrence is more frequent than distant metastases,demanding more thorough mediastinal lymph node dissection.

The impact of the number of occult metastatic lymph nodes on postoperative relapse of resectable esophageal cancer

Clinical stage II/III esophageal cancer (EC), as defined by the Japanese Classification, relapses at a moderately high rate even after curative resection. The number of lymph node metastases is known to be associated with tumor relapse. Recently, the prognostic significance of occult metastatic lymph nodes (MLNs), as well as that of overt MLNs, has been reported. The aim of this study was to investigate the impact of the total number of MLNs including occult MLNs on postoperative relapse in clinical stage II/III EC. One hundred and five patients with clinical stage II/III EC who underwent esophagectomy accompanied by radical lymphadenectomy at the Department of Surgical Oncology in Osaka City University Hospital between January 2000 and October 2008 were included in this study. Occult MLNs, metastases not detected by hematoxylin-eosin staining, were identified by immunohistochemistry (IHC) using antipancytokeratin antibody AE1/AE3. The clinicopathological features of occult MLNs were compared between the relapse and no relapse groups. A total of 6558 lymph nodes (1357 from two-field dissection and 5201 from three-field dissection) were examined by IHC staining; 362 overt MLNs and 143 occult MLNs were detected. The number of occult MLNs increased in proportion to the International Union Against Cancer pathological (p)N-status and pStage. When the number of occult MLNs was added to the number of pNs, the number of total MLNs was associated with postoperative relapse. With respect to tumor, node, metastasis stage, 6 of 22 patients (27%) who were pathological node-negative converted to node-positive by considering total MLNs. The number of N3 patients with relapse increased markedly with restaging by total MLNs. The number of total MLNs, but not overt MLNs, was an independent prognostic factor on multivariate analysis. These results suggest that occult MLNs were often found, and they were associated with postoperative relapse of resectable esophageal cancer. The total number of MLNs including occult MLNs could contribute to evaluating the precise stage of patients with esophageal cancer.

Negative lymph-node count is associated with survival in patients with resected esophageal squamous cell carcinoma

The number of recovered lymph nodes (LNs) is associated with the prognosis of patients with esophageal squamous cell carcinoma (ESCC) undergoing surgical resection. A relationship between negative LN count and patient outcome has been demonstrated in gastrointestinal cancers, including colon and gastric cancers. However, little is known about the prognostic significance of negative LN counts in ESCC. In this retrospective study we examined patient survival in relation to negative LN count in 252 patients with surgically resected ESCC. Cox proportional hazards models were used to compute hazard ratios (HRs) for death, adjusted for clinical and pathological characteristics. Negative LN count was associated with year of operation (P = .0015) and number of fields dissected (P < .0001) but not with tumor location, TNM (ie, tumor, node, metastasis) stage, N status, or histologic grade. Patients with ≥ 31 negative LNs experienced a reduction in overall mortality compared with those with 0-30 negative LNs (log-rank P = .0042; univariate HR = 0.48, 95% confidence interval 0.28-0.79, P = .0035; multivariate HR = 0.41, 95% confidence interval 0.21-0.76, P = .0039). The influence of negative LN count on overall survival was modified by the number of fields dissected (P for interaction = .033); more negative LNs were significantly associated with lower overall mortality in three-field dissection (log rank P < .0001) but not in two-field dissection (log rank P = .93). A negative LN count was associated with improved survival in patients with curatively resected ESCC.

Multicenter Prospective Randomized Trial Comparing Standard Esophagectomy With Chemoradiotherapy for Treatment of Squamous Esophageal Cancer: Early Results From the Chinese University Research Group for Esophageal Cancer (CURE)

We conducted a prospective randomized trial to compare the efficacy and survival outcome by chemoradiation with that by esophagectomy as a curative treatment. From July 2000 to December 2004, 80 patients with potentially resectable squamous cell carcinoma of the mid or lower thoracic esophagus were randomized to esophagectomy or chemoradiotherapy. A two- or three-stage esophagectomy with two-field dissection was performed. Patients treated with chemoradiotherapy received continuous 5-fluorouracil infusion (200 mg/m2/day) from day 1 to 42 and cisplatin (60 mg/m2) on days 1 and 22. The tumor and regional lymphatics were concomitantly irradiated to a total of 50-60 Gy. Tumor response was assessed by endoscopy, endoscopic ultrasonography, and computed tomography scan. Salvage esophagectomy was performed for incomplete response or recurrence. Forty-four patients received standard esophagectomy, whereas 36 were treated with chemoradiotherapy. Median follow-up was 16.9 months. The operative mortality was 6.8%. The incidence of postoperative complications was 38.6%. No difference in the early cumulative survival was found between the two groups (RR = 0.89; 95% confidence interval, 0.37-2.17; log-rank test P = 0.45). There was no difference in the disease-free survival. Patients treated with surgery had a slightly higher proportion of recurrence in the mediastinum, whereas those treated with chemoradiation sustained a higher proportion of recurrence in the cervical or abdominal regions. Standard esophagectomy or chemoradiotherapy offered similar early clinical outcome and survival for patients with squamous cell carcinoma of the esophagus. The challenge lies in the detection of residue disease after chemoradiotherapy.

Two-field dissection is enough for esophageal cancer.

Three-field lymphadenectomy for esophageal cancer remains controversial. The high prevalence of cervical lymph node involvement is the basis of cervical lymphadenectomy. Studies of recurrence patterns after esophagectomy, however, indicate that clinically relevant cervical nodal recurrence is uncommon, and that the incidence of such recurrence is similar to that of two-field lymphadenectomy. Moreover, a convincing survival benefit cannot be proven for the more extended lymphadenectomy. The emphasis of three-field lymphadenectomy has shifted to lymphadenectomy of the superior mediastinum and along the recurrent laryngeal nerve chains. Radical dissection of these areas may improve local disease control; the price to pay is increased postoperative morbidity and impaired long-term quality of life. Furthermore, the selection of appropriate patients for extended lymphadenectomy is difficult. Formal three-field lymphadenectomy seems unnecessary, but the controversy of the optimal extent of lymphadenectomy and its impact on survival remains unanswered.

Results of a Nationwide Study on the Three-Field Lymph Node Dissection of Esophageal Cancer

In order to determine the operative indications of three-field lymph node dissection of esophageal cancer, attempts were made to collect data concerning procedures performed between 1983 and 1989 in major institutions in Japan, and the results from institutions performing three-field or two-field lymph node dissection were compared. The treatment results of three-field lymph node dissection were better than those after two-field dissection, except for early or advanced cancer. The survival rate improved by the three-field as compared with the two-field lymph node dissection; however, since surgery was invasive, some complications such as recurrent nerve paralysis were frequent. The results show that the indication of three-field lymph node dissection has to be carefully determined for each patient.