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J Thorac Cardiovasc Surg 1994;107:1155
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Invited letter concerning: How extensive should lymph node dissection be for cancer of the thoracic esophagus?

Department of Surgery
Cancer Institute Hospital
1-37-1 Kami-Ikebukuro
Toshima-ku, Tokyo 170, Japan

Reply to the Editor:

We appreciate very much Dr. Skinner's approving comment about our article. Since 1957, we had systematically dissected the upper mediastinum through a right thoracotomy, as well as the middle and lower mediastinum and the upper abdomen, for cancer of the thoracic esophagus. We first found the lymph nodes along the right recurrent laryngeal nerve to be quite frequently involved. These we called "the highest right mediastinal nodes." Involvement of the lymph nodes along the left recurrent nerve also proved to be quite common. It was difficult to dissect all these nodes through a right thoracotomy incision. For this reason we have now incorporated dissection through a cervical incision.

Although the term "three-field dissection" has recently been used, this term may be misleading. For accurate discussion, the grouping of the lymph nodes must be objectively definite. The "three-fields" are cervical, mediastinal, and abdominal regions, but the cervical region is not a well-defined compartment. The cervical lymph nodes include both the deep cervical nodes (C group) and the cervical part of the lymph node chains along the recurrent nerves (U group). The jugular node chains belong to the former group. The latter group is in the same anatomic compartment as the upper mediastinum and is frequently involved, whereas the former is in a definitely distinct compartment and is rarely involved in earlier stages. Therefore, dissection of the C group might be avoided without adversely affecting survival. We hope those who plan to do a cervical dissection will take note of this difference.

Although we mainly referred to disease stages on the basis of lymph node status in this article, the depth of wall penetration is another important factor. This factor has a strong correlation with nodal status. We would like to add our another remarkable result: the U and perigastric (G) groups were more frequently involved than the middle and lower mediastinal (L) group in the early stage of wall penetration. The prevalences of T1 cancer in the U, L, and G groups were 25%, 11%, and 20%, respectively.

As Dr. Skinner pointed out, the TNM categorization should be modified. We would like to emphasize that a grading process always reduces the clinical information, because various kinds of information describing the disease status are simplified into a few categories after being graded. Therefore, a categorization in which the information loss is minimal should be used. We assessed the amount of information loss produced by grading based on a certain information criterion in another article, ¹ and we proved that a grading based on the total number of positive lymph nodes results in substantially less information loss than the present N categorization in the UICC system.

References

1. Matsubara T, Kaise O, Ishiguro M, et al. Better grading systems for evaluating the degree of lymph node invasion in cancer of the thoracic esophagus. Surg Today [In press].
   

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Matsurbara, T. Search for Related Content PubMed PubMed Citation Articles by Matsurbara, T.