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Journal meeting

Journal meeting. Esophagus cancer. Question : How extend lymphadenectomy is enough for esophagus cancer?. Background Data.

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Journal meeting

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  1. Journal meeting

  2. Esophagus cancer Question : How extend lymphadenectomy is enough for esophagus cancer?

  3. Background Data Increased number of regional lymph nodes containing metastases predicts decreased survival following esophagectomy for cancer, and increased extent of lymphadenectomy is associated with improved survival. Therefore, extend lymphadenectomy of some extent is required. However, what constitutes optimum lymphadenectomy to maximize survival is controversial.

  4. Lymphatic drainage of esophagus

  5. Radical esophagectomy should encompass all lymph node stations having a greater than 10% incidence of metastases • lymphatic metastasis cannot be diagnosed precisely either by ultrasonography or CT imaging before surgery. • Therefore, radical surgery for cancer of the thoracic esophagus requires complete

  6. three-field lymph node dissection. • upper mediastinal lymph nodes (including the node group of the recurrent laryngeal nerve chain)

  7. paratracheal lymph nodes on both sides , subcarinal, right and left hilar lymph nodes, posterior mediastinal lymph nodes adjacent to the descending aorta and left pleura, and diaphragmatic lymph nodes are dissected.

  8. For the abdominal procedure, after an upper midline laparotomy, en-bloc dissection of lymph nodes is carried out along the cardia, lesser curvature, left gastric artery, celiac axis, common hepatic artery, and splenic artery

  9. Method • Deta base : Worldwide Esophageal Cancer Collaboration data. • The entire project was approved by the Case Cancer Institutional Review Board of Case Western Reserve University. • Method : total of 4627 patients who had esophagectomy alone for esophageal cancer. (no pre- or postoperative adjuvant therapy) for esophageal cancer and had follow-up for all-cause mortality.) • Risk-adjusted 5-year survival was averaged for each number of lymph nodes resected.

  10. Method

  11. Result • pN0M0 Cancers • pTis cancers • regardless of histopathologic cell type, survival was excellent and not associated with extent of lymphadenectomy. • T1N0M0 cancers • G1 : survival was unrelated to extent of lymphadenectomy • G2/G3 cancers : survival was increased with more extensive lymphadenectomy

  12. Result • pN0M0 Cancers • T2N0M0 and T3/T4N0M0 cancers • G1 : limited data , due to few case number • G2/G3 cancers : survival was increased with more extensive lymphadenectomy • .

  13. Result • N+M0 Cancers • 1 to 6 nodes positive (N1~2) • survival increased with extent of lymphadenectomy for all T classifications • 7 or more nodes positive • T2 and T3/T4 cancers : Survival increased, albeit minimally, with extent of lymphadenectomy • T1 : very few case number to assessing the survival value

  14. Optimum Lymphadenectomy • pTis • no optimum extent of lymphadenectomy • pT1 N0M0 cancers • 10 for adenocarcinomas • 12 for squamous cell carcinomas • pT2 N0M0 cancers • 15 for adenocarcinomas • 22 for squamous cell carcinomas • T3/T4N0M0 cancers • 31 for Adenocarcinomas • 42 for squamous cell carcinomas Optimum number of nodes resected was determined by the value at which standardized VIMP first dropped below 5%.

  15. Optimum Lymphadenectomy • T2 N1~2M0 cancers(1 to 6 nodes) • 15 • T2 N3M0 cancers(7 or more nodes positive) • insufficient data were available • T3/T4N1M0 cancers • 29 • T3/T4N2M0 cancers • 50 • T3/T4N3M0 cancers • 28

  16. Discussion • Extent of lymphadenectomy was either unassociated with or minimally increased survival for patients with extremes of esophageal cancer (TisN0M0 and T2N3 lesion) and those with well-differentiated(G1) pN0 cancer. • pN+ cancers • improved survival!! • more accurate determination of number of positive nodes (stage purification), or therapeutic effect of removing micrometastases.

  17. Limitation • despite worldwide data, there was a paucity of cases at the extremes, such as well-differentiated (G1)pT3/T4N0 and pT2 N3. • No morbidity information according to extent of lymphadenectomy • The main problem is that each institution has a different method of counting the number of lymph nodes resected.

  18. Recommendations • If there is uncertainty as to T and histopathologic grade, it is recommended that 30 or more nodes be resected to maximize 5-year survival. • It is recommended that to maximize 5-year survival, a minimum of 10 nodes be resected for T1 cancer, 20 nodes for T2 cancer, and 30 or more nodes for T3/T4 cancers.

  19. Thanks for your attention!

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