Improved Surgical Results in Thoracic Esophageal Squamous Cell Carcinoma: A 40-year Analysis of 792 Patients

Extensive lymphadenectomy, including upper mediastinum, for thoracic esophageal carcinoma was introduced at the beginning of 1980s. However, the efficacy has not been analyzed in large series at a single institute. We evaluated factors potentially related to improved surgical results in patients with thoracic esophageal squamous cell carcinoma (SCC). From 1959 to 1998, a total of 792 patients with thoracic esophageal SCC underwent R0 surgery. A variety of clinicopathological factors were compared among patients treated from 1990 to 1998 (recent group, n = 164) and 1959 to 1989 (former group, n = 628). The recent group showed significantly better survival than the former group (5-year survival rates: 51 versus 17%, P < 0.01), partly because earlier stage disease was included in the recent group than in the former group. Multivariable analysis, using the Cox regression analysis, indicated the time period of surgery, age, tumor location, the number of positive nodes (>5), venous invasion, and tumor–node–metastasis stage. Upper mediastinum lymphadenectomy was also an independent factor to improve survival of patients with thoracic esophageal SCC. Based on multivariate analysis of 792 cases during 40-years experience on thoracic esophageal cancer surgery at Chiba University Hospital, upper mediastinum lymphadenectomy was found to be one of the independent prognostic factors to improve patient’s overall survival.     

Abdominal Lymph Node Metastasis in Patients with Mid Thoracic Esophageal Squamous Cell Carcinoma

Background  There are few reports about abdominal lymph node metastasis of mid thoracic esophageal carcinoma. This study was designed to explore the pattern of abdominal lymph node metastasis in patients with mid thoracic esophageal squamous cell carcinoma and to evaluate the prognostic factors. Methods  The complete data of 368 patients with mid thoracic esophageal squamous cell carcinoma, who underwent modified Ivor-Lewis esophagectomy with two-field lymphadenectomy from January 1998 to January 2003, were reviewed. Survival rate was calculated by Kaplan-Meier method. Cox regression analysis was performed to identify risk prognostic factors. Results  Abdominal lymph node metastasis occurred in 58 (15.8%) patients: 34.5% (20/58) of them were stage T1 and T2. Skipping abdominal node metastasis was recognized in 13.8% (8/58) patients: all were stage T1 and T2. The overall 5-year survival rate of patients with abdominal lymph node metastasis (10.3%) was lower than that of those with thoracic node metastasis (18.3%). The prognosis of patients with distant abdominal lymph node metastasis was poor, and no one could survive more than 5 years. Cox regression analysis showed that five or more positive nodes and distant abdominal node metastasis were independent risk factors of patients with abdominal lymph node metastasis. Conclusions  Abdominal lymph node metastasis in patients with mid thoracic esophageal squamous cell carcinoma occurred frequently, and the surgery favorable for extensive abdominal lymph node dissection should be selected. The prognosis of patients with abdominal lymph node metastasis was poor, especially those with more positive nodes and distant abdominal node metastasis.     

Pattern of lymph node metastases in patients with squamous cell carcinoma of the thoracic esophagus who underwent three-field lymphadenectomy

BACKGROUND/AIMS: Lymph nodes in patients with squamous cell carcinoma of the thoracic esophagus might be involved with metastases at cervical, mediastinal, and abdominal sites. The range of lymph node dissection is still controversial. The pattern of lymph node metastasis and factors that are correlated with lymph node metastasis affect the surgical procedure of lymph node dissection. The purpose of the present study was to explore the pattern of lymph node metastasis and factors that are correlated with lymph node metastasis in patients with esophageal cancer who underwent three-field lymphadenectomy. METHODS: Lymph node metastases in 230 patients who underwent radical esophagectomy with three-field lymphadenectomy were analyzed. The metastatic sites of lymph nodes were correlated with tumor location by chi-square test. Logistic regression was used to analyze clinicopathological factors related to lymph node metastasis. RESULTS: Lymph node metastases were found in 133 of the 230 patients (57.8%). The average number of resected lymph nodes was 25.3 +/- 11.4 (range 11-71). The proportions of lymph node metastases were 41.6, 19.44, and 8.3% in neck, thoracic mediastinum, and abdominal cavity, respectively, for patients with upper thoracic esophageal carcinomas, 33.3, 34.7, and 14%, respectively, in those with middle thoracic esophageal carcinomas, and 36.4, 34.1, and 43.2%, respectively, for patients with lower thoracic esophageal carcinomas. We did not observe any significant difference in lymph node metastatic rates among upper, middle, and lower thoracic carcinomas for cervical or thoracic nodes. The difference in lymph node metastatic rates for nodes in the abdominal cavity was significant among upper, middle, and lower thoracic carcinomas. The lower thoracic esophageal cancers were more likely to metastasize to the abdominal cavity than tumors at other thoracic sites. A logistic regression model showed that depth of tumor invasion and lymphatic vessel invasion were factors influencing lymph node metastases. CONCLUSIONS: Based on our data, cervical and mediastinal node dissection should be performed independent of the tumor location. Abdominal node dissection should be conducted more vigorously for lower thoracic esophageal cancers than for cancers at other locations. Patients with deeper tumor invasion or lymphatic vessel invasion were more likely to develop lymph node metastases.     

The pattern and prevalence of lymphatic spread in thoracic oesophageal squamous cell carcinoma

Background: Oesophageal squamous cell carcinoma (SCC) is a common type of cancer in China. The knowledge of its pattern of lymphatic metastasis would be of clinical value for surgical and radiation oncologists to treat this disease. Material and methods: A large series of 1850 thoracic oesophageal SCC was retrospectively analysed after extended oesophagectomy with three-field lymphadenectomy (3FL). Specimens were assessed for pattern of lymphatic spread. Result: Of the 1850 patients, 1081 (58.4%) developed mediastinal, cervical and/or abdominal node metastases. The lymphatic metastasis rates were 35.6%, 22.2%, 26.5%, 6.1% and 26.5%, respectively, for the cervical, upper, middle, lower mediastinal nodes and abdominal nodes. The adjacent mediastinal node metastasis alone occurred in 5.5% of patients, and the multiple level or skip node spread accounted for 20.9% and 73.6% of patients with node metastases. Upward lymphatic spread developed in 46.4% of patients, both up- and downward in 33.2%, and the downward, 20.5%. For the upper oesophageal SCC, the most common node metastasis was in the cervical (49.5%) and followed by the upper mediastinal (28.7%), middle mediastinal (11.4%), abdominal (8.0%) and lower mediastinal (1.4%) nodes. For the middle oesophageal SCC, the highest incidence of node spread was also in the cervical (35.0%) and similar rates in the middle mediastinal (29.8%), abdominal (27.2%) and upper mediastinal (22.4%) nodes, but the least in the lower mediastinal (6.0%) node. For the lower oesophageal SCC, more node metastasis occurred in the abdominal (51.7%), and followed by the middle mediastinal (25.6%), cervical (17.2%), lower mediastinal (13.9%) and upper mediastinal (10.0%). However, the lymphatic metastasis rates of the upper, middle and lower thoracic oesophageal SCC were similar. The unfavourable factors for lymphatic metastasis were long oesophageal lesion (p < 0.000), late T stage (p < 0.000) and poor differentiation of tumour cells (p < 0.000). Conclusion: The prevalence was: (1) lymphatic spread prone to the upward in the upper oesophageal SCC, downward in the lower one and both up- and downward in the middle one with in favour of the upward and (2) multiple level and skip node metastases were very often seen. The unfavourable factors for node spread were long oesophageal lesion, late T stage and poor differentiation of tumour cells.     

Status of Involved Lymph Nodes and Direction of Metastatic Lymphatic Flow Between Submucosal and T2-4 Thoracic Squamous Cell Esophageal Cancers

Background  Three-field lymph node dissection for thoracic esophageal cancer is associated with high morbidity and reduced quality of life after surgery. Consequently, minimized lymphadenectomy would be desirable, if appropriate. In the present study, we retrospectively analyzed the status of involved nodes and the direction of metastatic lymphatic flow from tumors into involved nodes to determine whether submucosal squamous cell esophageal cancers are potential candidates for minimized lymphadenectomy. Methods  We enrolled 199 patients who received esophagectomy with extensive lymph node dissection between 1989 and 2005 and retrospectively analyzed their prognoses, distribution of solitary metastatic lymph nodes, and the direction of metastatic lymphatic flow from the tumor, taking into consideration tumor location and depth. Results  Of these patients with submucosal cancers, 83% had 1 or 2 involved nodes, and their esophageal cancer-specific 5-year survival rate was 66%. Solitary lymph node metastasis did not occur in neck lymph nodes in lower thoracic submucosal esophageal cancers, and the direction of metastatic lymphatic flow from the tumor was almost always in one direction. By contrast, T2–4 cancers with 2–4 involved nodes had bidirectional metastatic lymphatic flow from the tumor. Conclusions  There was a difference in the status of lymph node metastasis and the direction of metastatic lymphatic flow from tumors into involved nodes between submucosal and T2–4 thoracic squamous cell esophageal cancers. This analysis may be useful for developing an approach to minimized lymphadenectomy for thoracic esophageal cancers.     

选择性颈胸腹三野淋巴结清扫治疗胸段食管鳞癌

目的 研究胸段食管鳞癌的淋巴结转移规律，探讨合适的淋巴结清扫范围。方法 87例接受食管次全切除术的胸段食管鳞癌患者，根据术前食管腔内超声和颈部超声检查结果，选择性进行胸腹二野或颈胸腹三野淋巴结清扫。结果 超声发现颈部淋巴结肿大并行三野清扫35例（40．2％，三野清扫组），其中原发肿瘤位于胸上段食管者的比例（16／24例，66．7％）显著高于中、下段肿瘤者（19／63例，30．2％）（P=0．002）。三野清扫术扫除淋巴结13．7组／例，显著多于二野清扫组（52例，59．8％）的10．5组／例（P〈0．001）。术后病理检测三野清扫组转移淋巴结1．5组／例，也显著多于二野清扫组的0．8组／例（P〈0．01）。颈淋巴结转移（pM1-LN）17例（占全组19．5％，占三野清扫组48．6％），有区域淋巴结转移者的颈淋巴结转移比例（15／48例，31．3％）显著高于无区域淋巴结转移者（2／39例，5．1％）（P〈0．01）。上、中、下纵隔及上腹部的淋巴结转移率分别为25．3％、23．O％、5．7％和24．1％，颈淋巴结转移与上纵隔（P〈0．01）及中纵隔（P〈0．01）淋巴结转移显著相关，但与下纵隔及上腹部淋巴结转移无关。三野清扫组术后并发症发生率（60．0％）显著高于二野清扫组（34．6％，P=0．020）。喉返神经损伤发生率两组差异无统计学意义（P〉0．05）；但喉返神经损伤者吻合口瘘发生率（7／13例，53．8％）显著高于无喉返神经损伤者（10／74例，13．5％，P=0．001）。术后死亡率两组差异无统计学意义（P〉0．05）。结论 应对肿瘤位于胸上段食管、或上纵隔及中纵隔淋巴结已发生转移的食管癌患者在超声指导下进行选择性颈胸腹三野淋巴结清扫术，以降低手术风险、提高手术根治效果。     

Multimodal Treatment for Lymph Node Recurrence of Esophageal Carcinoma After Curative Resection

Background  Although esophagectomy with extended lymph node dissection can improve survival of patients with esophageal carcinoma, lymph node metastasis has remained one of the main recurrence patterns. The aim of this study was to evaluate the outcome of intensive treatment for recurrent lymph node metastasis. Methods  Recurrent lymph node metastasis was detected in 68 patients with thoracic esophageal carcinoma after curative esophagectomy (R0, International Union Against Cancer criteria). Multimodal treatment was performed in 41 patients: 19 patients underwent lymphadenectomy with adjuvant therapy, and 22 received definitive chemoradiotherapy and repeated chemotherapy. The remaining 27 patients (40%) received chemotherapy or best supportive care. Results  Survival of the lymphadenectomy and the chemoradiotherapy groups was significantly better than that of the patients who received chemotherapy or best supportive care (P < .0001). Fifteen patients (79%) underwent curative lymph node dissection (R0) in the lymphadenectomy group. Complete response, partial response, and stable disease were obtained in 8 (37%), 10 (45%), and 4 (18%) patients who received chemoradiotherapy, respectively. There was no statistically significant difference in survival between the lymphadenectomy and the chemoradiotherapy groups. Although the location of lymph node metastasis did not influence survival significantly, seven patients with nodes around the abdominal aorta did not survive longer than 3 years. The most common repeat recurrence pattern was organ metastasis after the treatment. Multivariate analysis showed that the number of metastatic nodes and tumor marker were independent prognostic factors. Conclusion  Multimodal treatment including lymphadenectomy and chemoradiotherapy could improve survival of the patients with lymph node recurrence of esophageal carcinoma after curative resection.     

胸段食管鳞癌淋巴结转移规律探究

目的探讨胸段食管鳞癌淋巴结转移规律及其影响因素,以指导淋巴结清扫方式。方法回顾分析漳州市医院2010年4月至2012年7月手术治疗的328例胸段食管鳞癌的临床病理资料,探讨淋巴结转移规律及其影响因素。结果全组328例共清扫淋巴结9937枚,平均30．3枚／例。共437枚、153例有淋巴结转移,转移率46．65％;其中喉返神经旁淋巴结转移18．30％,10．46％喉返神经旁淋巴结为唯一转移部位。胸段食管癌淋巴结转移与肿瘤部位、长度、分化程度及浸润深度明显相关。胸上段食管癌淋巴结转移方向主要向上纵隔及下颈部;胸中段食管癌颈、胸、腹均可发生淋巴结转移;胸下段食管癌主要向腹腔、中下纵隔转移。结论食管上段鳞癌,颈部淋巴结转移率高,应行三野淋巴结清扫;下段食管癌清扫重点在腹腔、中下纵隔;中段鳞癌应提倡进行个体化清扫和适度清扫;分化程度差,浸润程度深的病例应适当扩大清扫范围。胸段食管癌喉返神经旁淋巴结转移率高,均应行喉返神经旁淋巴结清扫。     

Long-term Results after Dissection of Positive Thoracic Lymph Nodes in Patients with Esophageal Squamous Cell Carcinoma

Background Although thoracic lymph node metastasis in patients with thoracic esophageal squamous cell carcinoma (SCC) has been reported to be a negative risk factor for long-term survival, only a few studies have evaluated the clinicopathologic difference between the impact of metastasis to the paraesophageal lymph nodes and to the nonparaesophageal lymph nodes. The purpose of this study was to evaluate surgical outcome after the clearance of metastatic thoracic lymph nodes. Methods Retrospectively reviewed were 164 consecutive patients with thoracic esophageal SCC who had not had preoperative treatment and underwent surgery from 1980 to 2005 and were found to have thoracic lymph node metastases. Of these patients, 83 underwent surgery from 1980 to 1994 and 81 from 1995 to 2005. Univariate and multivariate analyses were performed to evaluate the impact of nonparaesophageal lymph node metastasis on survival. Results Univariate analysis revealed that T3/T4 tumors and the presence of nonparaesophageal node metastases were associated with only a 20% overall five-year survival rate. The overall five-year survival for the most recent period was significantly better than for the former period (42% vs. 13%, p < 0.01). Based on a multivariate analysis of prognostic impact of each nonparaesophageal node, the presence of metastatic subcarinal and/or posterior mediastinal nodes was an independent risk factor for reduced survival. Conclusion Surgical outcome for patients with thoracic esophageal cancer and metastatic thoracic lymph nodes has improved during the last 25 years. Although postoperative chemotherapy might improve survival, the presence of T3/T4 tumors and/or metastatic nonparaesophageal nodes were unfavorable factors for survival.     

T2胸中段食管鳞癌淋巴结转移特点和规律

目的 探讨T2胸中段食管鳞癌淋巴结转移特点和规律.方法 分析246例接受颈、胸、腹三野淋巴结清扫的T2胸中段食管鳞癌病人的临床病理指标与淋巴结转移的关系.结果 每例病人清扫淋巴结15～59枚,平均25枚.其中129例存在区域淋巴结转移.颈、胸和腹三区淋巴结转移率分别为28.9%、28.5%和22.0%,差异无统计学意义.Logistic回归模型显示肿瘤长度、肿瘤细胞分化程度及有无淋巴管血管浸润是影响淋巴结转移的有意义因素.结论 T2胸中段食管鳞癌淋巴结转移与肿瘤长度、肿瘤细胞分化程度及有无淋巴管血管浸润明显相关;T2胸中段食管鳞癌有上、下双向转移和跳跃性转移的特点,应行三野淋巴结清扫,对胸中段超出T2的食管鳞癌也应行以上手术.

Abstract：

Objective To investigate the pattern of lymph node metastasis in patients with 17 and middle thoracic esophageal squamous cell carcinoma( ESCC). Methods Retrospective review the clinical data of 246 cases with T2 and middle thoracic esophageal squamous cell carcinoma who were treated by three-field lymphadenectomy. Analyze the relationship between clinical pathological factors and lymph node metastasis. Results Lymph node metastases were found in 129 of the 246 patients (52.4% ).The average number of resected lymph nodes was 25 per patient (rangel5 -59). The rates of lymph node metastasis were 28.9% in the neck, 28.5% in thoracic mediastinum and 22.0% in abdominal cavity for patients with T2 and middle thoracic ESCC. No significant difference in lymph node metastasis' rate was observed among the neck, thoracic mediastinum and abdominal cavity. Logistic-regression showed the length of tumor, tumor cell differentiation and angiolymphatic invasion were factors influencing lymph node metastasis. Conclusion Lymph node metastasis in T2 and middle thoracic ESCC has the characteristics of upward, downward and skip spreading. Patients with T2 and middle thoracic ESCC should be treated with radical surgery with three-field lymphadenectomy.     

Cervical Nodal Metastasis from Intrathoracic Esophageal Squamous Cell Carcinoma is not Necessarily an Incurable Disease

Background  It remains controversial if metastatic cervical lymph nodes in patients with intrathoracic esophageal cancer signify distant metastases and are therefore incurable or if they should be regarded as regional spread with a potential for cure. Material and Methods  Patients with intrathoracic esophageal squamous cell carcinoma managed from 1995 to 2007, in whom metastatic cervical lymph node spread was confirmed by fine needle aspiration cytology, were studied. Treatment strategies and outcome were reviewed. Results  There were 109 patients, of whom 98 were men. Median age was 62 years (range, 34–88). Excluding those who underwent primarily palliative treatments, there were two main groups: 22 who had upfront chemoradiation therapy and subsequent esophagectomy ± cervical lymphadenectomy and 46 who had chemoradiation only. Significant downstaging occurred in 29 of the 68 patients (42.6%), of whom eight (11.8%) had complete pathological/clinical response. There was no mortality after esophagectomy. Median survival of patients with chemoradiation plus esophagectomy was 34.8 months compared to those with no surgery at 9.9 months, (p < 0.001). Patients with stage IV disease at presentation by virtue of nodal disease survived longer than those with the same stage because of systemic organ metastases: 9.3 vs. 3 months, (p < 0.001). Conclusions  Prognosis of patients with metastatic cervical nodes was not uniformly dismal. Up to 20% had reasonable survival after chemoradiation and surgical resection. Stage IV disease should be revised to segregate those with nodal and systemic metastases.     

胸段食管癌颈部及上纵隔淋巴结转移

探讨胸段食管癌颈部及上纵隔淋结转移规律。方法采用颈,胸,腹三切口施行胸段食管癌手术６１６例,同时施行三区域淋巴洁清扫。结果：中及上纵隔淋巴结转移率和转移度分别为５７．１％和２１．５％。结论胸段食管癌必须重颈部及上纵隔淋巴结清扫。     

Impact of the Number and Extent of Positive Lymph Nodes in 200 Patients with Thoracic Esophageal Squamous Cell Carcinoma after Three-field Lymph Node Dissection

Background Subtotal esophagectomy with three-field lymph node dissection (3FLD) has been reported to improve survival in patients with thoracic esophageal squamous cell carcinoma (SCC). The purpose of this study was to evaluate the prognostic impact of the extent and number of positive lymph nodes for long-term survival of patients who underwent 3FLD. Methods From January 1983 to December 2002, a total of 200 patients with thoracic esophageal SCC underwent 3FLD without any neoadjuvant therapy. The prognostic impact of the extent and number of positive lymph nodes was evaluated by both univariate and multivariate analysis. Results The extent of positive nodes associated with a 5-year survival were as follows: none, 69%; one-field, 50%; two-field, 29%; and three-field, 11%. The number of positive nodes associated with 5-year survival were as follows: single node, 65%; two-nodes, 51%; and more than three-nodes, 20%. Among patients with cervical lymphatic spreading, patients with upper tumors showed significantly better survival than patients with lower tumors (P = 0.036). Multivariate analysis indicated that number of positive nodes and the abdominal node status were independent prognostic factors among lymph node status. Conclusions Together, number and extent of positive lymph nodes can be considered an independent predictor of a high risk of recurrence. Although cervical lymphatic spreading was risk factor for worse survival, patients with upper tumors may have survival benefit after cervical lymph node dissection.     

胸中段食管鳞状细胞癌伴腹腔淋巴结转移及其预后的临床研究

目的 了解胸中段食管鳞状细胞癌伴腹腔淋巴结转移的方式,分析预后的影响因素.方法 对1998年1月至2003年1月接受手术治疗的368例胸中段食管鳞状细胞癌患者进行回顾性研究.本组男性289例,女性79例,年龄38～79岁,平均56岁.术前临床分期I～Ⅲ期.全部患者采用Ivor-Lewis手术(右胸及上腹部两切口)行食管大部切除加胸腹二野淋巴结清扫.全组患者平均随访时间68个月.结果 腹腔淋巴结转移58例(15.8%),其中T1-2患者占36.2%(21/58);有13.8%(8/58)的患者为跳跃性腹腔淋巴结转移,均发生在T1-2患者中.腹腔淋巴结转移患者5年生存率为10.3%,低于胸腔淋巴结转移患者的18.3%.远处腹腔淋巴结转移患者预后极差,无1例达到5年生存(0/16).COX多因素分析结果 显示,淋巴结转移数目≥5枚和远处腹腔淋巴结转移是腹腔淋巴结转移患者的独立预后因素.结论 胸中段食管癌腹腔淋巴结转移的发生率较高,应该选择有利于腹腔淋巴结广泛清扫的手术方式.腹腔淋巴结转移患者的预后不良,尤其淋巴结转移数目较多和远处淋巴结转移的患者预后更差.     

Clinical implications of cervical lymph node metastasis patterns in thoracic esophageal cancer.

OBJECTIVE. The authors attempt to clarify the clinical implications of cervical lymph node metastases from thoracic esophageal cancers. SUMMARY BACKGROUND DATA. Cervical lymph node metastases from thoracic esophageal cancer have been considered to be incompatible with curative resection. However, recent studies have demonstrated that cure is achievable in patients with such metastases. METHODS. Patterns of esophageal cancer metastasis to the cervical nodes and long-term results after tumor resection were investigated in 23 patients undergoing bilateral cervical lymphadenectomy for treatment of thoracic esophageal cancer. RESULTS. The number of positive nodes per patient was significantly greater (p < 0.05) in lower esophageal cancers (median: 15) than in upper or mid esophageal cancers (median: 2.5). Simultaneous metastases to three nodal regions (the neck, mediastinum, and abdomen) were significantly more common (p < 0.001) in lower esophageal tumors (88.9%) than in upper and mid esophageal lesions (7.1%). Although the overall 5-year survival rate was 16.5%, long-term survival was achieved only in patients with upper or mid esophageal cancer.     

Surgical outcome after the clearance of abdominal metastatic lymph nodes in 138 patients with thoracic esophageal carcinoma

BACKGROUND: Although abdominal lymph node metastasis in patients with thoracic esophageal squamous cell carcinoma (SCC) has been reported to be a risk factor to reduce long-term survival, only a few studies have so far evaluated the clinicopathologic factors among this group of patients. The purpose of this study was to evaluate the patients' surgical outcome after the clearance of metastatic abdominal nodes. PATIENTS AND METHODS: From 1980 to 2002, 550 consecutive patients with thoracic esophageal SCC underwent surgery with an abdominal lymph node dissection. A total of 138 patients with abdominal lymph node metastases were curatively resected. Those patients, including 62 from 1980 to 1989 and 76 from 1990 to 2002, were retrospectively reviewed. Univariate and multivariate analyses were performed to evaluate the impact of clinicopathologic factors on the survival of these patients. RESULTS: The overall 5-year survival rate of the 138 patients with abdominal lymph node metastases was 23%. A univariate analysis revealed that the following groups showed a greater than 30% overall 5-year survival rate: patients with T1 or T2 tumors, patients without thoracic node metastases, and those with poorly differentiated type tumors. Good prognostic factors based on a multivariate analysis were the most recent time period of surgery and 4 or fewer positive nodes. CONCLUSION: Among the patients with abdominal lymph node metastases, those with T1 or T2 tumors, patients without thoracic node metastases, and patients with 4 or fewer positive nodes showed an acceptable overall survival after a curative resection.     

食管癌淋巴结转移特点及其危险因素

目的 探讨食管癌淋巴结转移情况及其危险因素,为外科手术行淋巴结清扫提供参考。方法回顾总结2006年1月至2010年12月在复旦大学附属肿瘤医院胸外科行三野淋巴结清扫食管癌根治术308例患者的临床资料．分析淋巴结的转移规律及特点。结果308例患者平均清扫淋巴结（35．6±14．5）枚,197例（64％）患者出现淋巴结转移。Logistic单因素分析结果显示,脉管（淋巴管及血管）侵犯（P=0．019）及肿瘤浸润深度（P〈0．001）是发生淋巴结转移的危险因素。各站淋巴结中,胸部气管旁淋巴结转移率最高（25．0％）。上段食管癌腹部淋巴结转移率显著低于中段或下段食管癌（P=0．001）,而各段食管癌颈胸部淋巴结转移率比较,差异无统计学意义（P〉0．05）。颈胸部和颈胸腹部淋巴结转移率分别为14．6％和11．0％,而颈腹部和胸腹部则分别为3．6％和4．9％。脉管侵犯（P〈0．001）和胸部气管旁淋巴结转移（P=0．014）是食管癌发生颈部淋巴结转移的危险因素。结论食管癌淋巴结转移具有上、下双向和跳跃性的特点．胸部气管旁淋巴结转移可作为行颈部淋巴结清扫的指征。     

Optimal lymphadenectomy for squamous cell carcinoma in the thoracic esophagus: comparing the short- and long-term outcome among the four types of lymphadenectomy

Abstract Controversy continues over the optimal extent of lymphadenectomy (regional versus three-field) for a potentially resectable squamous cell carcinoma in the thoracic esophagus. In the Consensus Conference of the International Society for Diseases of the Esophagus (ISDE), held in Munich in 1994, the types of lymphadenectomy were classified as standard, extended, total, or three-field lymphadenectomy. The objective of the present study was to determine the optimal procedure among these four types of lymphadenectomy. The mortality and morbidity rates, postoperative course, and survival rates were compared among 302 patients who underwent curative (R0) transthoracic esophagectomy with one of these four types of lymphadenectomy at Kurume University Hospital, Fukuoka, Japan, from 1986 to 1998. Three-field lymphadenectomy resulted in better survival than any other type of lymphadenectomy for patients with positive lymph node metastasis from a cancer in the upper or middle thoracic esophagus. A postoperative complication, such as recurrent laryngeal nerve paralysis, anastomotic leakage, and tracheal ischemic lesion, was significantly more common after three-field lymphadenectomy. However, the mortality rate was the same among the four procedures. Three-field lymphadenectomy was optimal for an upper or middle thoracic esophageal cancer with metastasis in the lymph node(s) based on improved long-term survival, whereas there was not a large difference in short-term and long-term outcomes after the four types of lymphadenectomy for a lower thoracic esophageal cancer. Electronic Publication     

Prediction of Lymph Node Status in Superficial Esophageal Carcinoma

Background  Esophageal carcinoma is among the cancers with the worst prognosis. Real chances for cure depend on both early recognition and early treatment. The ability to predict lymph node involvement allows early curative treatment with less invasive approaches. Aims  To determine clinicohistopathological criteria correlated with lymph node involvement in patients with early esophageal cancer (T1) and to identify the best candidate patients for local endoscopic or less invasive surgical treatments. Methods  A total of 98 patients with pT1 esophageal cancer [67 with squamous cell carcinomas (SCC) and 31 with adenocarcinomas (ADK)] underwent Ivor–Lewis or McKeown esophagectomy in the period between 1980 and 2006 at our institution. Based on the depth of invasion, lesions were classified as m1, m2, or m3 if mucosal, and sm1, sm2, or sm3 if submucosal. Results  The rates of lymph node metastasis were 0% for the 27 mucosal carcinomas (T1m) and 28% for the 71 submucosal (T1sm) carcinomas (P < 0.001). Sm1 carcinomas were associated with a lower rate of lymph-node metastasis (8.3% versus 49 % sm2/3, P  = 0.003). As for histotype, the rates of lymph node metastasis for sm1 were 0% for ADK and 12.5% for SCC; for sm2/3 there were no significant differences. On multivariate analysis, depth of infiltration, lymphocytic infiltrate, angiolymphatic and neural invasion were significantly associated with lymph node involvement. Neural invasion was the single parameter with the greatest accuracy (82%); depth of infiltration and angiolymphatic invasion had 75% accuracy. Altogether these three parameters had an accuracy of 97%. Five-year survival rate was 56.7% overall: 77.7% for T1m and 53.3% for T1sm (P  = 0.048). Conclusions  The most important factors for predicting lymph node metastasis in early esophageal cancer are depth of tumor infiltration, angiolymphatic invasion, neural invasion and grade of lymphocytic infiltration. The best candidates for endoscopic therapy are tumors with high-grade lymphocytic infiltration, no angiolymphatic or neural invasion, mucosal infiltration or sm1 (only for ADK), and tumor <1 cm in size. For sm SCC and sm2/3 ADK the treatment of choice remains esophagectomy with standard lymphadenectomy.     

选择性三野淋巴结清扫术治疗胸段食管鳞癌的临床研究

目的分析行选择性三野淋巴结清扫术对胸段食管鳞癌患者的预后影响。 方法2009年6月至2012年9月,四川省肿瘤医院对127例胸段食管癌患者根据肿瘤的位置、外侵程度、术前颈部超声检查结果,进行选择性三野淋巴结清扫。全组共127例患者,其中上段49例;中段67例;下段11例;Ⅰ期2例,Ⅱ期26例,Ⅲ期99例。 结果127例患者共清扫淋巴结4963枚,平均每例清扫淋巴结39.3枚;手术时间(325.6±9.3)min,出血量(316.0±18.7)ml。术后76例患者发生并发症,发生率为59.8%(76/127)病死率为1.6%(2/127)。选择性三野淋巴结清扫术后喉返神经旁淋巴结转移率40.2%(51/127);颈部淋巴结转移率55.9%(71/127),其中,胸中下段食管鳞癌颈部淋巴结转移与喉返神经转移显著相关(χ²＝0.005,P＝0.006)。全组中位生存时间(35.0±1.9)个月,3年生存率51.8%。其中Ⅱ期中位生存时间(42.1±3.4)个月,3年生存率74.5%;Ⅲ期生存时间(32.3±2.0)个月,3年生存率44.8%,两组间比较差异有统计学意义(χ²＝3.940,P＝0.047)。颈部淋巴结阳性患者的中位生存时间(26.2±2.1)个月,3年生存率34.9%;阴性患者中位生存时间(41.5±2.3)个月,3年生存率67.6%,差异有统计学意义(χ²＝15.283,P<0.001)。 结论选择性三野淋巴结清扫术是一种安全可行、可提高颈部淋巴结清扫率,同时又能筛选出潜在获益患者、延长生存的手术方式。