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고려대학교 구로병원 김현구

Two vs. Three Field Lymph Node Dissection in Surgery for Esophageal Cancer. 고려대학교 구로병원 김현구. Incision vs. LN Dissection. Ivor-Lewis Two-hole Two-incision. Two-field. McKweon Three-hole Tri-incision. Three-field. Case-1. M/61 G-fiber: 39cm from incisor

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고려대학교 구로병원 김현구

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  1. Two vs. Three Field Lymph Node Dissection in Surgery for Esophageal Cancer 고려대학교 구로병원 김현구

  2. Incision vs. LN Dissection Ivor-Lewis Two-hole Two-incision Two-field McKweon Three-hole Tri-incision Three-field

  3. Case-1 M/61 G-fiber: 39cm from incisor Biopsy: Squamous cell carcinoma Stage: cT1N0M0 Treatment?

  4. Case-2 M/63 G-fiber: 25~28cm from incisor Biopsy: severe dysplasia with leiomyoma Stage: cT1N0M0 Treatment?

  5. Case-3 M/49 G-fiber: 26~28cm from incisor Biopsy: Squamous cell carcinoma Stage: cT1N0M0 Treatment?

  6. Two-Field or Three-Field ? Tumor location Depth of tumor invasion Tumor cell type Substantial morbidity Prognostic benefit Quality of life Tumor location Depth of tumor invasion Tumor cell type

  7. Optimal Surgical Extent ? Minimal Radical • Advancement of • operative technique • Advancement of • perioperative • management • Systemic disease • Palliative • Advancement of • chemotherapy & • radiotherapy

  8. Categorization of Esophageal Segment Cervical Upper thoracic Mid thoracic Lower thoracic Abdominal

  9. Lymphatic Drainage Multidirectional lymphatic flow

  10. Lymphatic Drainage Lymph-capillary network in submucosal space Submocosal plexus Regional (N1) & non-regional lymph nodes (M1a & M1b) Regional lymphatics (N1) Thoracic duct & the systemic venous circulation (M1b) Abundant lymph-capillary network in the submucosal longitudinal lymphatic drainage (vs. segmental in colon ca.) Rice TW, Lancet, 1999, Hosch SB, JCO, 2001, Lerut, Ann Surg, 2004 ☞Widespread and random patterns of lymph node metastasis Ando N, Ann Surg, 2000 Skip metastasis: 50~60% MatsubaraT, Cancer, 2000

  11. Lymph Node Mapping System

  12. Lymph Node Mapping System

  13. Patterns of Metastatic Nodal Spread

  14. Patterns of Metastatic Nodal Spread Association with tumor location-1 Akiyama H, Ann Surg 1994. Altorki N, Ann Surg 2002 ☞ 3-field LN dissection

  15. Patterns of Metastatic Nodal Spread Association with tumor location-2 Nodal metastasis is a rare finding three levels away from the location of the tumor. It is most common in the same level as the tumor and one level adjacent to the tumor. The involvement of lymph nodes that are two levels away from the location of the tumor is also very common but to a lesser extent. Patients with carcinoma in the upper thoracic esophagus rarely had metastasis in the abdominal nodes, while those with carcinoma in the lower thoracic esophagus rarely had metastasis in the cervical nodes. Kato H, J Surg Oncol 1991 Sharma S, Surg Today 1994 ☞ 2-field LN dissection

  16. Patterns of Metastatic Nodal Spread Association with depth of tumor invasion-1 Rice TW, Ann ThoracSurg 1998

  17. Patterns of Metastatic Nodal Spread Association with depth of tumor invasion-2 Matsubara T, Br J Surg 1999 ☞ T stage ↑→ LN Metastasis↑

  18. Patterns of Metastatic Nodal Spread Association with tumor cell type ☞ No difference Sheids 6th edition

  19. Extent of Resection Axial margin Taking account shrinkage of the specimen after resection as a guide to surgery, an in-situ margin of 10cm (fresh contracted specimen of ~5cm) should be aimed to, allow a less than 5% chance of anastomotic recurrence. Siu KF, Ann Surg 1986 Law S, Am J Surg 1998

  20. Extent of Resection Lymphadenectomy Mediastinal lymph node dissection Standard 2-field Extended 2-field Total 2-field Abdominal lymph node dissection or Cervical lymph node dissection Pearson, 3rd edition

  21. Cervical Esophagus Distant metastasis: 20% Regional metastasis: 63% Median survival: 11~14months 5-year survival: 14~21% 5-year survival was significantly low when regional neck LN involved (8% vs. 38%) However, regional LN involvement was not prognostic parameter in multivariate analysis Marmuse JP, Am J Surg, 1995 Triboulet JP, Arch Surg, 2001

  22. Upper Thoracic Esophagus In resectable T3 squamous cell carcinoma, o 3-year survival No difference Limited resection 14% 20% Extended LN dissection Manshanden CG Eur J Surg Oncol 2000 Igaki H, Br J Surg 2005 ☞ Although cervical lymph node dissection is important for staging, curative surgery for cervical-upper esophageal cancer combined with extended lymph node dissection is probably only indicated in selected cases without distant lymph node metastasis. BresadolaF, ORL J OtorhinolaryngolRelat Spec 2001

  23. Middle & Lower Thoracic Esophagus In Japan, 70% of the esophageal carcinoma occurs in the middle thoracic esophagus. Ando N, Ann Surg 2000 Tachibana M, Am J Surg 2005 Nine of 141 patients with middle esophageal cancer had cervico-thoracic nodal involvement. →3-field LN dissection proved to be important for correct staging. In lower thoracic esophageal carcinoma, no patient had cervico-upper thoracic LN involvement. → Patients with negative upper thoracic LN not necessarily have to undergo a 3-field LN dissection. Involved celiac nodes were found in tumors at all three locations. → For esophageal tumors investigation of celiac LN is worthwhile.

  24. Cervical LN Metastasis in Esophageal Cancer • 14~30% patients: metastasis to cervical lymph nodes 40% for upper third tumors 20% for lower third tumors • Frequency of nodal metastasis: increased with depth of tumor penetration Intramucosa < submucosa < muscularispropria < adventitia 30% < 50% < 60% < 80% • LNs in both recurrent laryngeal nerves frequently have metastasis. Isono K, 1991, Oncology ☞ Extended radical esophagectomy with 3-field LN dissection ☞ Improving accuracy of staging & better local control

  25. 5 –Year Survival in 2- vs. 3-Field LN Dissection Akiyama H, Am J Surg. 1984

  26. Skeptical Views to 3-Field LN Dissection-1 • Systemic disease Replaced by neoadjuvant chemotherapy or intraoperative radiotherapy • Hospital mortality: 4% Increased morbidity: 44.8% Recurrent laryngeal nerve palsy: 16~58% Pulmonary complication: 21.3% Anastomotic leak: 19~30% Septic complication: 27% Decreased QOL Severe hoarseness, restricted food intake, reduced exercise tolerance: 20%

  27. Skeptical Views to 3-Field LN Dissection-2 • No prognostic benefit Recurrence rate in cervical LN: 11% Isolated cervical nodal recurrence: 4% vs. Mediastinum(21%),systemic organ metastasis(26%) ☞ Minimal role of cervical LN dissection • Prospective Randomized study

  28. LN Dissection along Recurrent Laryngeal Nerve Recurrent laryngeal LN + cervical LN →Cervicothoracic group

  29. Selective 3-Field LN Dissection

  30. Sentinel Lymph Node The first lymph node within the lymphatic basin reached by lymph draining from the primary lesion

  31. Limited Reports Complicated compared to gastric cancer Limited No. of early esophageal cancer The frequency of metastasis in SLN was significantly higher LN involvement was found in only 2% of the non-SLN Kitagawa Y, Surg Clin North Am 2000 The preoperative mapping of SLN based on the lymphoscintigraphy Improved the accuracy of the intraoperative gamma probing Baciewicz FA, Jr., J Invest Surg 2000

  32. ProcedurePreoperation 1 day before surgery Radioisotope injection 4 hours after injection Lymphoscintigram Kitagawa, Gen Thorac Cardiovasc Surg, 2008

  33. ProcedureIntraoperation Percutaneous gamma probing Gamma probing through thoracotomy or thoracoscopy Dual tracer method Radioisotope Blue dye: endoscopically injection right before surgery

  34. SLN Mapping in Esophageal Cancer • Predict overall lymph node status • Tailored extent of lymphadenectomy Avoid unnecessery morbidity and mortality for node- negative patients More radical treatment for node-positive patients • More detailed examination to optimize disease staging of target specific nodal tissue Step sectioning Immunochemistry RT-PCR • Determination of the radiation field during CCTR

  35. SLN Mapping in EMR Organ preservation treatment : EMR, PDT, Argon plasma coagulation

  36. KUGH Experiences Duration: November 2007~ March 2009 Patients:T1~3 N0M0 squamous esophageal cancer Radioisotope: 99mTc-neomannosyl human serum albumin (99mTc-MSA)

  37. Results

  38. Conclusions • Curative surgery for cervical-upper esophageal cancer combined with extended LN dissection is probably only indicated in selected cases without distant LN metastasis. • 3-field LN dissection proved to be important for correct staging in middle esophageal cancer. • In lower thoracic esophageal carcinoma, patients with negative upper thoracic LN not necessarily have to undergo a 3-field LN dissection. • No statistical difference in survival was found in randomized trials comparing an extensive LN dissection with a limited lymphadenectomy. • Selective LN dissection using sentinel lymph node mapping have to be further evaluated before it can be applied widely.

  39. THANK YOU !

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