Debate 2: Optimal Lymph Node Dissection - Limited vs Extended (for Limited)

Abstract

The optimum extent of lymphadenectomy for esophageal cancer has been controversial. The old debate revolved around transhiatal versus transthoracic esophagectomy. The argument not only involves which approach is safer, but inherent within the treatment philosophy is whether lymphadenectomy is beneficial, assuming that only the transthoracic method offers adequate exposure for thorough systematic nodal dissection. Proponents of transhiatal esophagectomy claim that the approach is safer, result in less cardiopulmonary complications, and long-term survival is not compromised. The one randomized controlled trial comparing the two methods with adenocarcinomas of the lower esophagus and gastroesophageal junction only showed more postoperative complications with the transthoracic approach. On an intent-to-treat basis, no survival difference was found. For squamous cell carcinomas, three-field extended lymphadenotomy is practiced by limited number of centers. The small number of randomized controlled trials in Japan could not show a convincing advantage. Morbidity from such extended nodal dissection is substantial, especially with regards to cardiopulmonary complications and recurrent laryngeal nerve palsy. Studies on recurrence patterns in patients with only standard two-field lymph node dissection show limited value in adding the third field. Isolated neck recurrences are uncommon, and mostly systemic recurrences predominate, diminishing the role of extended dissection. Thus there is inadequate evidence to prove that extended lymphadenectomy imparts a survival advantage, certainly it improves staging accuracy, but the price is increased morbidity. It is arguable that in very selected patients, extended nodal dissection may increase cure rate. However the number of such patients would likely be small, and preoperative selection is difficult. Limited lymphadenectomy should be the standard-ofcare for most patients with esophageal cancer.