Three-field lymph node dissection in esophageal cancer surgery

Abstract

Although multidisciplinary treatment has improved the prognosis of esophageal cancer, it is commonly associated with one of the worse prognoses. Since lymph node (LN) metastases can primarily occur from the cervical to the abdominal field, a strategy for extended LN dissection has been established. The three field LN dissection (3FD) during a transthoracic esophagectomy which is defined as a procedure for cervico-thoraco-abdominal LN dissection, was established in the 1980s' in Japan, and is currently widely accepted throughout the world. To date, various comparative trials between 3FD and two field LN dissections (2FD) have been reported and show that a transthoracic esophagectomy with 3FD is superior to 2FD for prognosis. However, in 3FD, postoperative complications, such as recurrent laryngeal nerve palsy and postoperative gastrointestinal dysfunction can be induced. Furthermore, there are few prospective trials that have compared between 2FD and 3FD. Therefore, to determine the ideal range of LN dissection, various factors (e.g., location of the primary tumor, disease progression, tumor histology, and perioperative treatment) must be considered. Recently, the efficacy of intense perioperative treatment for esophageal cancer has been reported, and the significance of minimally invasive surgical procedures are being verified. The ideal combination of perioperative treatment and feasible surgery must be established to improve the oncological outcome of esophageal cancer patients further.

Minimally invasive oesophagectomy with extended lymph node dissection and thoracic duct resection for early-stage oesophageal squamous cell carcinoma

“…For early disease stages including cT1 N0, transthoracic oesophagectomy with lymphadenectomy is a valid treatment option. Because the number of lymph nodes (LNs) removed is associated with prognosis and three‐field LN dissection may improve survival, transthoracic oesophagectomy with radical LN dissection may be the best treatment. There is, however, variation in the extent of mediastinal LN dissection.…”

Mediastinal lymphadenectomy for esophageal cancer: Differences between two countries, Japan and the Netherlands

“…Distribution of metastatic lymph nodes (LN) may vary with different factors such as tumor location, tumor histology and biology, tumor invasion depth, length of the tumor (stage) and use of neoadjuvant therapy . Surgical strategy depends on the distribution pattern of nodal metastases, but consensus on the extent of lymphadenectomy differs worldwide …”

“…In the Netherlands, the majority of esophageal surgeons carry out the so‐called two‐field lymphadenectomy in different extensions, never the total mediastinal lymphadenectomy as done in Japan, where the three‐field lymphadenectomy is currently used for upper and middle SCC …”

Genomic evidence supports a clonal diaspora model for metastases of esophageal adenocarcinoma

“…Treatments may therefore be unnecessarily toxic (e.g. radical lymphadenectomy and high dose chemotherapy) or lead to under-treatment with high recurrence rates (Lou et al, 2013; Matsuda et al, 2017; Waterman et al, 2004).…”

“…Prognosis is highly variable for EAC patients and with a wide range in the proportion of patients surviving beyond 5 years (18-47% in patients with lymph node involvement) making it difficult to advise patients when embarking on a long course of grueling treatment (Cunningham et al, 2008; Waterman et al, 2004). Despite the clinical classification of EAC as curative or non-curative, depending on the location of associated lymph nodes (Japanese Gastric Cancer, 2011) and involvement of solid organs, controversy exists in the field concerning whether radical lymph node dissection improves outcome (Matsuda et al, 2017; Stiles et al, 2012; Waterman et al, 2004).…”