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Three-Field Lymphadenectomy for Carcinoma of the Esophagus and Gastroesophageal Junction in 174 R0 Resections: Impact on Staging, Disease-Free Survival, and Outcome: A Plea for Adaptation of TNM Classification in Upper-Half Esophageal Carcinoma

Lerut, T MD, PhD*; Nafteux, P MD*; Moons, J RN, MScN*; Coosemans, W MD, PhD*; Decker, G MD*; De Leyn, P MD, PhD*; Van Raemdonck, D MD, PhD*; Ectors, N MD, PhD

doi: 10.1097/01.sla.0000145925.70409.d7
Original Articles and Discussions
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Objective: To determine the impact of esophagectomy with 3-field lymphadenectomy on staging, disease-free survival, and 5-year survival in patients with carcinoma of the esophagus and gastroesophageal junction (GEJ).

Background: Esophagectomy with 3-field lymphadenectomy is mainly performed in Japan. Data from Western experience with 3-field lymphadenectomy are scarce and dealing with relatively small numbers. As a result, its role in the surgical practice of cancer of the esophagus and GEJ remains controversial.

Methods: Between 1991 and 1999, primary surgery with 3-field lymphadenectomy was performed in 192 patients, of whom a cohort of 174 R0 resections was used for further analysis.

Results: Hospital mortality of the whole series was 1.2%. Overall morbidity was 58%. Pulmonary complications occurred in 32.8%, cardiac dysrhythmias in 10.9%, and persistent recurrent nerve problems in 2.6%. pTNM staging was as follows: stage 0, 0.6%; stage I, 9.2%; stage II, 27.6%; stage III, 28.7%; and stage IV, 33.9%. Overall 3- and 5-year survival was 51% and 41.9%, respectively. The 3- and 5-year disease-free survival was 51.4% and 46.3%, respectively. Locoregional lymph node recurrence was 5.2%; no patient developed an isolated cervical lymph node recurrence. Five-year survival for node-negative patients was 80.2% versus 24.5% for node-positive patients. Five-year survival by stage was 100% in stages 0 and I, 59.1% in stage II, 36.8% in stage III, and 13.3% in stage IV. Twenty-three percent of the patients with adenocarcinoma (25.8% distal third and 17.6% GEJ) and 25% of the patients with squamous cell carcinoma (26.2% middle third) had positive cervical nodes resulting in a change of pTNM staging specifically related to the unforeseen cervical lymph node involvement in 12%. Cervical lymph node involvement was unforeseen in 75.6% of patients with cervical nodes at pathologic examinations. Five-year survival for patients with positive cervical nodes was 27.7% for middle third squamous cell carcinoma. For distal third adenocarcinomas, 4-year survival was 35.7% and 5-year survival 11.9%. No GEJ adenocarcinoma with positive cervical nodes survived for 5 years.

Conclusions: Esophagectomy with 3-field lymph node dissection can be performed with low mortality and acceptable morbidity. The prevalence of involved cervical nodes is high, regardless of the type and location of tumor resulting in a change of final staging specifically related to the cervical field in 12% of this series. Overall 5-year and disease-free survival after R0 resection of 41.9% and 46.3%, respectively, may indicate a real survival benefit. A 5-year survival of 27.2% in patients with positive cervical nodes in middle third carcinomas indicates that these nodes should be considered as regional (N1) rather than distant metastasis (M1b) in middle third carcinomas. These patients seem to benefit from a 3-field lymphadenectomy. The role of 3-field lymphadenectomy in distal third adenocarcinoma remains investigational.

Three-field lymphadenectomy was performed in 192 patients. R0 resection was obtained in 174 patients. Twenty-five percent (41 of 174) had cervical lymph node involvement resulting in a TNM change (stage IV) in 12%. Overall 5-year survival was 41.9%, being 80% for lymph node-negative patients (n = 52). Locoregional lymph node recurrence occurred in 5.2% of the patients (n = 9), distant metastasis in 28.5% (n = 49), and both locoregional lymph node recurrence and distant metastasis in 10% (n = 17). Patients with middle third squamous cell carcinoma had a 5-year survival of 27%. Cervical lymph node involvement in these patients should be classified as regional lymph node involvement (N1) and not as distant lymph node disease (M1b).

From the *Departments of Thoracic Surgery and †Pathology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium.

Other members of the Leuven Collaborative Working Group for Esophageal Carcinoma are as follows: E. Van Cutsem (Digestive Oncology); M. Hiele, I. Demedts (Endoscopy); S. Stroobants (Nuclear Medicine); W. De Wever, S. Dymarkowski (Radiology); and K. Haustermans (Radiotherapy).

Reprints: Prof. Dr. T. Lerut, University Hospitals Leuven, Department of Thoracic Surgery, Herestraat 49, 3000 Leuven, Belgium. E-mail: Toni.Lerut@uz.kuleuven.ac.be.

© 2004 Lippincott Williams & Wilkins, Inc.