Lerut T, Nafteux P, Moons J, Coosemans W, Decker G, De Leyn P, Van Raemdonck D, Ectors N
Department of Thoracic Surgery, University Hospital Gasthuisberg, University of Leuven, Herestraat 49, 3000 Leuven, Belgium.
Ann Surg. 2004 Dec;240(6):962-72; discussion 972-4. doi: 10.1097/01.sla.0000145925.70409.d7.
To determine the impact of esophagectomy with 3-field lymphadenectomy on staging, disease-free survival, and 5-year survival in patients with carcinoma of the esophagus and gastroesophageal junction (GEJ).
Esophagectomy with 3-field lymphadenectomy is mainly performed in Japan. Data from Western experience with 3-field lymphadenectomy are scarce and dealing with relatively small numbers. As a result, its role in the surgical practice of cancer of the esophagus and GEJ remains controversial.
Between 1991 and 1999, primary surgery with 3-field lymphadenectomy was performed in 192 patients, of whom a cohort of 174 R0 resections was used for further analysis.
Hospital mortality of the whole series was 1.2%. Overall morbidity was 58%. Pulmonary complications occurred in 32.8%, cardiac dysrhythmias in 10.9%, and persistent recurrent nerve problems in 2.6%. pTNM staging was as follows: stage 0, 0.6%; stage I, 9.2%; stage II, 27.6%; stage III, 28.7%; and stage IV, 33.9%. Overall 3- and 5-year survival was 51% and 41.9%, respectively. The 3- and 5-year disease-free survival was 51.4% and 46.3%, respectively. Locoregional lymph node recurrence was 5.2%; no patient developed an isolated cervical lymph node recurrence. Five-year survival for node-negative patients was 80.2% versus 24.5% for node-positive patients. Five-year survival by stage was 100% in stages 0 and I, 59.1% in stage II, 36.8% in stage III, and 13.3% in stage IV. Twenty-three percent of the patients with adenocarcinoma (25.8% distal third and 17.6% GEJ) and 25% of the patients with squamous cell carcinoma (26.2% middle third) had positive cervical nodes resulting in a change of pTNM staging specifically related to the unforeseen cervical lymph node involvement in 12%. Cervical lymph node involvement was unforeseen in 75.6% of patients with cervical nodes at pathologic examinations. Five-year survival for patients with positive cervical nodes was 27.7% for middle third squamous cell carcinoma. For distal third adenocarcinomas, 4-year survival was 35.7% and 5-year survival 11.9%. No GEJ adenocarcinoma with positive cervical nodes survived for 5 years.
Esophagectomy with 3-field lymph node dissection can be performed with low mortality and acceptable morbidity. The prevalence of involved cervical nodes is high, regardless of the type and location of tumor resulting in a change of final staging specifically related to the cervical field in 12% of this series. Overall 5-year and disease-free survival after R0 resection of 41.9% and 46.3%, respectively, may indicate a real survival benefit. A 5-year survival of 27.2% in patients with positive cervical nodes in middle third carcinomas indicates that these nodes should be considered as regional (N1) rather than distant metastasis (M1b) in middle third carcinomas. These patients seem to benefit from a 3-field lymphadenectomy. The role of 3-field lymphadenectomy in distal third adenocarcinoma remains investigational.
确定食管癌和胃食管交界部（GEJ）癌患者行三野淋巴结清扫的食管切除术对分期、无病生存期和5年生存率的影响。
三野淋巴结清扫的食管切除术主要在日本开展。西方关于三野淋巴结清扫的经验数据较少且样本量相对较小。因此，其在食管癌和GEJ癌手术治疗中的作用仍存在争议。
1991年至1999年间，192例患者接受了三野淋巴结清扫的初次手术，其中174例R0切除患者的队列用于进一步分析。
整个系列的医院死亡率为1.2%。总体发病率为58%。肺部并发症发生率为32.8%，心脏心律失常发生率为10.9%，持续性喉返神经问题发生率为2.6%。pTNM分期如下：0期，0.6%；I期，9.2%；II期，27.6%；III期，28.7%；IV期，33.9%。总体3年和5年生存率分别为51%和41.9%。3年和5年无病生存率分别为51.4%和46.3%。局部区域淋巴结复发率为5.2%；无患者发生孤立性颈部淋巴结复发。淋巴结阴性患者的5年生存率为80.2%，而淋巴结阳性患者为24.5%。按分期的5年生存率在0期和I期为100%，II期为59.1%，III期为36.8%，IV期为13.3%。23%的腺癌患者（远端三分之一为25.8%，GEJ为17.6%）和25%的鳞状细胞癌患者（中三分之一为26.2%）有阳性颈部淋巴结，导致pTNM分期改变，具体与12%的患者中意外的颈部淋巴结受累有关。病理检查时，75.6%有颈部淋巴结的患者颈部淋巴结受累是意外发现的。中三分之一鳞状细胞癌颈部淋巴结阳性患者的5年生存率为27.7%。对于远端三分之一腺癌，4年生存率为35.7%，5年生存率为11.9%。无GEJ腺癌颈部淋巴结阳性患者存活5年。
三野淋巴结清扫的食管切除术可在低死亡率和可接受的发病率下进行。无论肿瘤类型和位置如何，受累颈部淋巴结的发生率都很高，导致本系列中12%的患者最终分期改变与颈部区域有关。R0切除术后总体5年生存率和无病生存率分别为41.9%和46.3%，可能表明有实际的生存获益。中三分之一癌颈部淋巴结阳性患者的5年生存率为27.2%，表明在中三分之一癌中，这些淋巴结应被视为区域淋巴结（N1）而非远处转移（M1b）。这些患者似乎从三野淋巴结清扫中获益。三野淋巴结清扫在远端三分之一腺癌中的作用仍在研究中。
