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J Thorac Cardiovasc Surg 1994;107:1154-1155
© 1994 Mosby, Inc.
LETTERS TO THE EDITOR |
The New York Hospital–Cornell Medical Center
Professor of Surgery
525 East 68th St.
New York, NY 10021
To the Editor:
The role and type of surgical treatment for cancer of the esophagus remain among the major controversies in oncology. Undoubtedly influenced by current trends in breast cancer therapy, many North American surgeons, radiation therapists, and medical oncologists view esophageal cancer as a systemic disease when it has advanced beyond the mucosa and accordingly view surgical resection as a purely palliative and perhaps even irrelevant therapy. On the other hand, neoplasms of the esophagus are part of digestive tract cancers as opposed to cancers of endocrine-regulated organs. For other digestive tract cancers the importance of adequate resection margins and lymph node removal has an acknowledged and significant impact on survival and curability.
In 1982 my colleagues and I 
1 reported that not only the depth of esophageal wall penetration but the actual number of diseased lymph nodes removed, rather than the simple presence of lymph node metastases, add a significant impact on survival in patients treated by an en bloc resection of the region surrounding the cancer-bearing esophagus. Among patients without full-thickness penetration of the esophagus, those with one to four abnormal lymph nodes removed in the en bloc specimen had approximately a 50% chance at long-term survival without recurrence, whereas those with the larger number of diseased lymph nodes died early of recurrent disease. Clearly, spread to a limited number of lymph nodes did not uniformly indicate systemic disease.
The article by Matsubara and colleagues in this issue (see page 1073) adds important information to knowledge about the role of lymph node removal in esophageal cancer. For more than a decade, Japanese colleagues have been evaluating the role of "three-field" cervical, mediastinal, and upper abdominal lymph node dissection as curative treatment for esophageal cancer. 2 Long-term results of these studies are now forcing reconsideration of the extent and role of lymph node dissection. En bloc esophagectomy for thoracic esophageal cancer introduced in 1969 and reported in 1983 was based on the concept that some patients with spread beyond the esophageal wall by direct penetration or adjacent lymph node metastases could still be cured by removal of the regional disease. 3 This proved to be the case in those few patients with stage IIA or IIB carcinoma and led eventually to a change in the TNM staging system whereby the T factor became depth of wall penetration rather than tumor size.
However, the results from Japanese analyses of lymph node spread in the "third-field" dissection, such as the current article, raise the question as to whether early spread is defined as local penetration and involvement of adjacent lymph nodes or whether spread to more remote lymph nodes may occur at an early and still curable stage.
In 1986, Tanabe and associates 4 reported studies on esophageal lymph flow after radioisotope injection into the thoracic esophagus before subsequent resection. The flow from the midthoracic esophagus routinely was detected in upper mediastinum and cervical lymph nodes as well as left gastric lymph nodes. Reports such as that of Matsubara and colleagues now indicate that patients with only one or few diseased lymph nodes may have these located in the upper mediastinum or neck or in the gastric lymph node distribution without having diseased local paraesophageal nodes adjacent to the tumor. Survival rates after resection in such patients in this series are impressive. Clearly lymph node metastases in the upper mediastinal, base of neck, or gastric regions do not preclude curability if only one or few nodes are involved. Such upper mediastinal and cervical nodes would not be included in an en bloc resection for cure of middle and lower third thoracic esophageal cancer.
After a similar report by Kato and coworkers 5 in 1991 indicating that patients with limited cervical lymph node metastases might still be curable, we reviewed sites of recurrence in patients treated by en bloc resection. Among 20 patients with squamous cell carcinoma in whom all lymph nodes in the mediastinal and upper abdominal fields were free of cancer, three (15%) had recurrence in the neck. Among 18 patients having recurrence after resection for Barrett's adenocarcinoma, four had cervical lymph node metastases. Along with the Japanese and subsequent European reports, these findings have led us to include the upper mediastinal and cervical lymph node regions as an addition to the en bloc resection for potentially curable thoracic esophageal cancer during the past 18 months.
There remains a need to change the International Union Against Cancer (UICC) and American Joint Committee on Cancer (AJCC) staging systems to recognize that the N category should be divided into N0, N1, and N2 cases. As yet, there is no consensus as to the dividing point between N1 (one or few diseased lymph nodes) versus N2 (multiple diseased lymph nodes). Data are being accumulated by the TNM committee of the International Society for Diseases of the Esophagus, which ideally will lead to a specific recommendation in the near future. European data such as those recently reported by Siewert and colleagues 6 add further support to the concept that patients with few or a small proportion of cancerous lymph nodes among many resected may still have a significantly favorable prognosis after extensive resection. Whatever final number from one to seven or less than 20% of resected lymph nodes malignant proves to be the answer will depend greatly on the numbers of lymph nodes resected and their careful identification by pathologists. Nevertheless, the principle should now be established that patients with metastases to one or a few lymph nodes can be cured by extensive surgery and that these lymph nodes need not be located only adjacent to the primary tumor.
References
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