Differences in Esophageal Cancer Surgery in Terms of Surgical Approach and Extent of Lymphadenectomy: Findings of an International Survey

Abstract

Introduction Esophagectomy and lymphadenectomy are essential parts of the multimodal treatment of esophageal carcinoma with curative intent. Treatment regimens vary globally and are subject to debate. A global survey was designed to gain insight into current practice. Methods Fifty-seven international expert upper gastrointestinal surgeons received a personal invitation to participate in the survey, which focused on demographics and experience; extent of lymphadenectomy in adeno and squamous cell carcinoma; use of classification systems; neoadjuvant therapy; surgical approach; and specimen handling. Results The response rate was 88% (50/57 surgeons), with a mean age of 51.6 years and a median number of 15 years of experience in esophageal surgery. The variety in the extent of lymphadenectomy in proximal, middle and distal squamous cell carcinoma, and Siewert I, II and III adenocarcinoma, was considerable. The number of different combinations of lymph node (LN) stations that were resected in the same tumor was high, while the number of surgeons who removed the exact same combination of LN stations was low. Illustrative is Siewert I adenocarcinoma, in which 27 unique combinations of LN stations were resected, with a maximum of two surgeons performing the exact same dissection. Use of neoadjuvant therapy, surgical approach, and specimen handling also show great variety among participants. Conclusion There is no uniform, worldwide strategy for surgical treatment of esophageal cancer. The extent of lymphadenectomy shows great variation for both histologic types. An international observational study is needed to provide evidence on the distribution pattern of lymph node metastases in esophageal cancer and the necessary extent of lymphadenectomy. Electronic supplementary material The online version of this article (10.1245/s10434-019-07316-9) contains supplementary material, which is available to authorized users.

<p>The Role of Adjuvant Chemoradiotherapy Over Radiotherapy After R0 Resection for Stage II-III Esophageal Squamous Cell Carcinoma</p>

“…6 Ten years later in 2019, results from an international survey still indicated that there was no uniform, worldwide strategy for surgical treatment of EC. 7 Additionally, given the growing recognition that even after being clinically well staged using ultrasound, some T 2 N 0 esophageal cancers (between 20-25%) may be upstaged to pathologic T 3 and/or lymph node-positive disease; thus, numerous patients could be referred for postoperative therapy for TESCC. 8 Compared with the classic combination of 5-Fu and cisplatin (DDP) with RT for EC, preclinical data have shown that paclitaxel (PTX) could enhance the radiation sensitivity of tumor cells, potentiate the antitumor response rate and increase the therapeutic ratio of RT.…”

Distribution of lymph node metastases in esophageal carcinoma [TIGER study]: study protocol of a multinational observational study

“…In the Netherlands, among other countries, curative treatment for patients with esophageal carcinoma consists of neoadjuvant chemoradiation followed by surgery [21, 22]. The radiation field during neoadjuvant treatment and the lymphadenectomy during surgery depend on the location of lymph node metastases but no consensus has been reached on the extent of the lymphadenectomy [23]. If a distribution pattern of lymph node metastases of esophageal carcinoma can be identified, the optimal neoadjuvant and surgical treatment can be determined.…”

Lymph node dissection and recurrent laryngeal nerve protection in minimally invasive esophagectomy

“…The difference in pathologic types, surgical practices, and nominalization of LN stations have existed in different countries, even among different surgeons. 12 The N stage is determined by the number of positive LNs in the AJCC/UICC TNM classification system for EC, but there are no principles for the extent of LN dissection. 38 The Japan Esophageal Society has proposed a more precise but complex N staging system, in which regional LNs are divided into N1-N3 levels according to different stations.…”

“…However, until now, there has been no widely accepted LN dissection mode for EC worldwide because different pathological types of ECs have different oncobiological features and different patterns of LN metastasis. 12 Before the 1980s, esophagectomy was performed through the right or left thoracotomies with two-field lymphadenectomy (2FL), including thoracic and upper abdominal LNs. Both in Japan and China, it was reported that postoperative recurrences were frequently found in the cervicothoracic region.…”