Download Optimum Lymphadenectomy

Journal meeting
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Esophagus cancer
• Question : How extend
lymphadenectomy is enough for
esophagus cancer?
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Background Data
• Increased number of regional lymph nodes containing
metastases predicts decreased survival following
esophagectomy for cancer, and increased extent of
lymphadenectomy is associated with improved
survival.
• Therefore, extend lymphadenectomy of some extent
is required.
• However, what constitutes optimum
lymphadenectomy to maximize survival is
controversial.
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Lymphatic drainage of
esophagus
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• Radical esophagectomy should encompass all lymph
node stations having a greater than 10% incidence of
metastases
• lymphatic metastasis cannot be diagnosed precisely
either by ultrasonography or CT imaging before
surgery.
• Therefore, radical surgery for cancer of the thoracic
esophagus requires complete
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three-field lymph node
dissection.
• upper mediastinal lymph nodes (including the node
group of the recurrent laryngeal nerve chain)
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• paratracheal lymph nodes on both sides , subcarinal,
right and left hilar lymph nodes, posterior mediastinal
lymph nodes adjacent to the descending aorta and left
pleura, and diaphragmatic lymph nodes are dissected.
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• For the abdominal procedure, after an upper
midline laparotomy, en-bloc dissection of lymph
nodes is carried out along the cardia, lesser
curvature, left gastric artery, celiac axis,
common hepatic artery, and splenic artery
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Method
• Deta base : Worldwide Esophageal Cancer
Collaboration data.
• The entire project was approved by the Case Cancer
Institutional Review Board of Case Western Reserve
University.
• Method : total of 4627 patients who had esophagectomy
alone for esophageal cancer. (no pre- or postoperative
adjuvant therapy) for esophageal cancer and had followup for all-cause mortality.)
• Risk-adjusted 5-year survival was averaged for each
number of lymph nodes resected.
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Method
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Result
pN0M0 Cancers
pTis cancers
regardless of histopathologic cell type, survival was
excellent and not associated with extent of
lymphadenectomy.
T1N0M0 cancers
G1 : survival was unrelated to extent of
lymphadenectomy
G2/G3 cancers : survival was increased with more
extensive lymphadenectomy
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Result
pN0M0 Cancers
T2N0M0 and T3/T4N0M0 cancers
G1 : limited data , due to few case number
G2/G3 cancers : survival was increased with more
extensive lymphadenectomy
•.
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Result
N+M0 Cancers
1 to 6 nodes positive (N1~2)
survival increased with extent of lymphadenectomy
for all T classifications
7 or more nodes positive
T2 and T3/T4 cancers : Survival increased, albeit
minimally, with extent of lymphadenectomy
T1 : very few case number to assessing the
survival value
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Optimum Lymphadenectomy
 pTis
 no optimum extent of lymphadenectomy
 pT1 N0M0 cancers
 10 for adenocarcinomas
 12 for squamous cell carcinomas
 pT2 N0M0 cancers
 15 for adenocarcinomas
 22 for squamous cell carcinomas
 T3/T4N0M0 cancers
 31 for Adenocarcinomas
 42 for squamous cell carcinomas
Optimum number of
nodes resected was determined by the
value at which standardized
VIMP first dropped below 5%.
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Optimum Lymphadenectomy
 T2 N1~2M0 cancers(1 to 6 nodes)
 15
 T2 N3M0 cancers(7 or more nodes positive)
 insufficient data were available
 T3/T4N1M0 cancers
 29
 T3/T4N2M0 cancers
 50
 T3/T4N3M0 cancers
 28
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Discussion
 Extent of lymphadenectomy was either unassociated
with or minimally increased survival for patients with
extremes of esophageal cancer (TisN0M0 and
T2N3 lesion) and those with well-differentiated(G1)
pN0 cancer.
 pN+ cancers
improved survival!!
more accurate determination of number of positive
nodes (stage purification), or therapeutic effect of
removing micrometastases.
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Limitation
 despite worldwide data, there was a paucity of cases
at the extremes, such as well-differentiated
(G1)pT3/T4N0 and pT2 N3.
 No morbidity information according to extent of
lymphadenectomy
 The main problem is that each institution has a
different method of counting the number of lymph
nodes resected.
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Recommendations
 If there is uncertainty as to T and histopathologic
grade, it is recommended that 30 or more nodes be
resected to maximize 5-year survival.
It is recommended that to maximize 5-year
survival, a minimum of 10 nodes be resected for
T1 cancer, 20 nodes for T2 cancer, and 30 or more
nodes for T3/T4 cancers.
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Thanks for your atten
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