Esophagectomy with Three Field
Lymph Node Dissection
Nothing to Disclose
Nasser K. Altorki, M.D.
Professor of Cardiothoracic Surgery
Department of Cardiothoracic Surgery
Esophagectomy with Three Field
Lymph Node Dissection
Nasser K. Altorki, M.D.
Professor of Cardiothoracic Surgery
Department of Cardiothoracic Surgery
Three Field Lymph Node Dissection
(1983-1989)
n
%M/M
Recurrent
nerve injury
5-year
Survival
3-field
1791
2.8/54
20%
34%
2-field
2799
4.6/56
14%
23%
Isono,1991
Occult Cervical Nodal Metastasis in Esophageal
Cancer: Preliminary Results of Three-Field
Lymphadenectomy
Squamous carcinoma
Adenocarcinoma
20
18
7/38 (18.4%) had cervical nodal
recurrence
Access is not sufficiently descriptive
En-bloc + 3 field dissection
Surgical approach
Posterior Mediastinectomy
Mobilized Specimen
Third Field (sup.mediastinum)
Third Field (sup.mediastinum)
Neck dissection
Abdominal Dissection
Predictive Factors for Positive CRL nodes
Factor
Subgroup
Number
patients
Positive CRL
nodes
Squamous cell
55
36%
Histology
0.02
Adenocarcinoma
130
20%
Middle
37
38%
Location
Induction
therapy
P-value
0.04
Lower / GEJ
148
22%
No
Yes
90
95
24%
24%
NS
Predictive Factors for Positive CRL nodes
Factor
Clinical T
classification
Subgroup
Number
patients
Positive CRL
nodes
cT0-2
42
17%
0.04
cT3-4
118
33%
T0-2**
71
16%
pT classification
pN
classification
P-value
0.02
T3-4
114
31%
N0
55
0%
N1
42
17%
<0.001
N2
45
38%
N3
43
51%
Multivariate Analysis
Variable
Adjusted
OR
95% CI
Clinical Presentation
0.86
0.26-2.92
pN classification
(N2, N3 vs. N0, N1)
17.57
5.84-52.86
5.68
2.1-15.36
Histology
(Squamous cell vs.
adenocarcinoma)
Overall Survival:
± CRL nodes
Overall 5 year survival:
No CRL nodes: 44.8%
Positive CRL nodes: 24.9%
Radical 3-Field Esophagectomy
 Feasible with low mortality (2%).
 Local recurrence < 5%.
 Survival exceeds 40%.
 Cervical nodal metastasis occurs in 25%
of patients.
 Prolonged survival may be possible in advanced disease
especially in patients with squamous cell carcinoma.
 Over 50% of patients still succumb to systemic disease
demonstrating the need for novel and better systemic therapy.
Conclusions
 The incidence of positive CRL nodes is high in patients
with esophageal cancer, despite being rarely identified
clinically
 Low rates of CRL nodes are present with early clinical
presentation, pT0-2, and pN0 status, particularly in
adenocarcinoma and in GEJ tumors
 Dissection of the CRL nodal field should be performed:
 In squamous cell carcinoma
 In adenocarcinoma with advanced disease by
pathologic factors