Reflections on three field lymphadenectomy in carcinoma of the esophagus and gastroesophageal junction.

BACKGROUND/AIMS: One of the most controversial questions in the surgical treatment of carcinoma of the esophagus and gastroesophageal junction (GEJ) is the extent of lymph node dissection, in particular the value of the cervical lymph node dissection (the so-called third field).

METHODOLOGY

This study reflects a single institution's experience with this extensive lymphadenectomy, the technique of which is described in detail.

RESULTS

Adding the third field to the lymph node dissection markedly improved accuracy of staging. Unforeseen involvement of lymph nodes in the neck was found in 30%. In T3N+ tumors of the GEJ, as much as 16.6% of positive lymph nodes were detected in the neck. Locoregional recurrence without distant metastasis was found in 6 patients (17.8%) out of a group of 37 patients with a minimum follow-up of 5 years. All 6 patients had stage IV disease because of distant lymph node metastasis (M+Ly). In 3 of these patients, locoregional recurrence occurred only after 3 years or more. In a subsequent series of 100 esophagectomies performed between 1992 and July 1993 no difference in outcome between radical versus standard resection was noticed for early stage I and II. However, there is a tendency towards a better estimated 5-year survival in favor of radical dissections (21%) versus standard resection (12%) in stage III and IV.

CONCLUSIONS

Extensive three field lymphadenectomy can be safely performed without increasing hospital mortality (0%) and morbidity. Improved accuracy of staging, prolonged disease-free survival and potential increased cure rate are confirmed by our experience. Survival obtained with this technique has to be compared with survival obtained by other, multimodality treatment forms.