Two-step three-field lymph node dissection is beneficial for thoracic esophageal carcinoma

Abstract

Aggressive surgery including extensive lymph node dissection is considered necessary to improve the long-term survival of patients with esophageal carcinoma. While three-field lymph node dissection is widely performed for patients with thoracic esophageal carcinoma, cervical lymph node metastasis is uncommon. In order to reduce surgical stress, we have developed a two-step three-field lymph node dissection procedure for thoracic esophageal carcinoma. In the first-step operation, total thoracic esophagectomy through a right thoracotomy is performed. Mediastinal and abdominal lymph node dissection is performed synchronously. When recurrent nerve lymph node metastasis is pathologically positive, cervical lymph node dissection is performed about 3 weeks after the first operation (second step). Of 343 patients with carcinoma of the esophagus surgically treated in our department between 1990 and 2001, 146 underwent the operation described above. Three-field dissection was performed in 68 patients (group A), while two-field dissection was performed in 78 patients (group B). In the 68 group A patients, cervical lymph node metastasis was positive in 15 patients (22%). There was no marked difference in the onset of major complications between the two groups. The 5-year survival rate was 58% for group A and 61% for group B, not a statistically significant difference. In 78 of the 146 patients, it was possible to avoid cervical lymph node dissection without negatively affecting therapeutic outcomes. Two-step three-field lymph node dissection can reduce surgical stress of patients with good clinical outcome.

Three-field lymph node dissection in treating the esophageal cancer

“…Meanwhile, there's also some series showed the similar surgical outcomes in Table 2 with the 5-year OS rates range from 41.9% to 73.2% (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)51), which is better than the outcome of 2-FL in Table 4 (14,16,(22)(23)(24). The mortality rates maintained between 1.2% and 10.4%, which is lower than that in 2-FL (14,16,(22)(23)(24)(25). Akiyama (52) reported the significant survival difference between 2-FL and 3-FL (38.3% versus 55.0% P=0.0013) after R0 resection in 717 patients.…”

“…Thus the way of treating the esophageal cancer is contradicted. Series showed in Tables 2,4 have already demonstrated that 3-FL in patients with squamous cell carcinoma of the thoracic esophagus with higher survival and less mortality and morbidity when compared with 2-FL (14,16). Even some western scholars have reported the outcomes of 3-FL as well.…”

“…The 5-year survival was 66.2% and 48.0%, and the recurrence rate was 19.9% and 24.1%, which drew the conclusion that 3-FL may prevent recurrence and prolong survival after thoracic esophagectomy. However, from Table 3, the morbidity after 3-FL is high, which is ranged from 46-80% (13,(15)(16)(17)(18)(19)(20), and it is not difficult to find the most frequently happened after 3-FL was pulmonary complications (13)(14)(15)(16)18), comparing with the anastomotic leakage and recurrent nerve injury. Fang et al (20) report with the significant higher respiratory failure (70.6% versus 31.6%, P=0.045) and death rate (47.1% versus 15.8%, P=0.047) in primary postoperative complications group than in secondary complications group after 3-FL, and it accounts for not only the more morbidity but also the more mortality after three-field lymph node dissection in Table 2.…”

“…In some eastern countries like Japan and China, where the main type of the esophageal cancer is the squamous cell, and it usually locates in the middle and lower esophagus. So the 2-FL, which is referred to the 2F, as a standard surgical treatment has been widely used (14,16,23), and the 3-FL also has been frequently conducted in China in recent years (26,27). However, in some western countries, the adenocarcinoma of the lower esophagus or the esophagogastric junction is common.…”

“…This method not only extended the range of conducting the 3-FL, but also improved the accuracy of 3-FL (68%). At the same time, in order to reduce the surgical stress, Noguchi et al (14) developed the two-step 3-FL for patients with thoracic esophageal cancer. In the first step operation, the total thoracic esophagectomy through a right thoracotomy with mediastinal and abdominal lymph node dissection is performed.…”