Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.
Dis Esophagus. 2012 Feb;25(2):146-52. doi: 10.1111/j.1442-2050.2011.01222.x. Epub 2011 Jul 15.
Para-aortic lymph node (PALN) recurrence is often seen in patients with lower thoracic esophageal cancer treated by esophagectomy with extended lymph node dissection. However, the clinicopathological characteristics of patients with PALN metastasis and the significance of PALN dissection are unknown. A total of 283 patients with lower thoracic esophageal cancer underwent esophagectomy with lymphadenectomy at our hospital between April 1984 and March 2007. Among these 283 patients, 60 patients were enrolled in this retrospective study according to following criteria: (i) clinical T2 to T4 tumor, (ii) no clinical PALN metastasis, and (iii) received PALN dissection. PALN dissection was indicated by a tumor depth of at least T2 and no severe complications. The clinicopathological data, recurrence pattern, and overall survival were compared between patients with PALN and without PALN metastasis. The mean length of surgery was 587 min and the mean blood loss was 1383 mL. The morbidity was 33.3% and mortality was 5% in this series. Sixteen patients (26.7%) had PALN metastasis; these showed significantly more lymph node metastases (15.8 ± 13.2 vs. 3.0 ± 3.2, P < 0.0001) and significantly worse survival rates (53.3% vs. 79.9% at 1 year, 6.7% vs. 62.0% at 3 years, P < 0.0001) than patients without PALN metastasis. The incidence of lymph node recurrence (P < 0.0001) and hematogenous recurrence (P= 0.0487) was also higher in patients with PALN metastasis than in patients without PALN metastasis. Among the 16 patients with PALN metastasis, a univariate analysis revealed total number of metastatic nodes < 8 (P= 0.0325) to be a significant prognostic factor. A multivariate logistic regression analysis of the regional lymph nodes identified the invasion of the lower mediastinal nodes (hazard ratio = 6.120) and retroperitoneal nodes (hazard ratio = 15.167) to be significantly correlated with PALN metastasis. PALN metastasis is suggested to be related to the systemic spread of lymphatic metastasis even in lower thoracic esophageal cancer. PALN dissection for pathological PALN(+) patients should not be performed. It remains to be determined in future prospective studies whether patients without pathological PALN metastasis, but showing PALN micrometastasis, could achieve improved survival with PALN dissection.
para-aortic 淋巴结 (PALN) 复发在接受食管癌根治术伴扩大淋巴结清扫术的患者中较为常见。然而，PALN 转移患者的临床病理特征以及 PALN 清扫的意义尚不清楚。
1984 年 4 月至 2007 年 3 月期间，我院共有 283 例胸下段食管癌患者接受了食管癌根治术伴淋巴结清扫术。在这 283 例患者中，根据以下标准选择 60 例患者进行回顾性研究：（i）临床 T2 至 T4 肿瘤，（ii）无临床 PALN 转移，（iii）接受 PALN 清扫。PALN 清扫指征为肿瘤深度至少 T2 且无严重并发症。比较有和无 PALN 转移患者的临床病理资料、复发模式和总生存率。
本系列手术平均时间为 587 分钟，平均出血量为 1383ml。该系列的发病率为 33.3%，死亡率为 5%。16 例（26.7%）患者有 PALN 转移；这些患者的淋巴结转移明显更多（15.8±13.2 比 3.0±3.2，P<0.0001），生存率明显更差（1 年时 53.3%比 79.9%，3 年时 6.7%比 62.0%，P<0.0001）。与无 PALN 转移患者相比，有 PALN 转移患者的淋巴结复发（P<0.0001）和血行复发（P=0.0487）发生率也更高。
在 16 例有 PALN 转移的患者中，单因素分析显示转移淋巴结总数<8 个（P=0.0325）是一个显著的预后因素。对区域淋巴结的多因素 logistic 回归分析显示，下纵隔淋巴结（危险比=6.120）和腹膜后淋巴结（危险比=15.167）侵犯与 PALN 转移显著相关。
即使在胸下段食管癌中，PALN 转移也提示与淋巴转移的全身扩散有关。对于病理 PALN（+）患者，不建议进行 PALN 清扫。在未来的前瞻性研究中，还需要确定是否无病理 PALN 转移但显示 PALN 微转移的患者进行 PALN 清扫能否提高生存率。
