Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada; Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland.
Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada.
Ann Thorac Surg. 2023 Jul;116(1):130-136. doi: 10.1016/j.athoracsur.2023.02.053. Epub 2023 Mar 12.
Surgical resection after neoadjuvant therapy remains the cornerstone of curative management of esophageal adenocarcinoma and is frequently used for squamous cell carcinoma. The optimal extent of lymphadenectomy and whether increasing lymph node yields confer a survival benefit remains unclear. Guidelines suggest resecting and examining a minimum of 15 lymph nodes at esophagectomy. This study assessed the impact of lymph node yield and lymph node ratio (LNR) on survival, identifying factors influencing nodal yield and radicality of resection.
All patients undergoing esophagectomy with curative intent at a single institution (stage 1-4 inclusive) from January 1, 2010, to December 31, 2020, were reviewed. Clinical and pathologic variables were interrogated. LNR was calculated by dividing positive lymph nodes by the total nodes resected.
Esophagectomy was performed in 397 patients, with 288 undergoing minimally invasive esophagectomy (MIE). Margin status (hazard ratio [HR], 1.80; 95% CI, 1.15-2.83; P < .01), nodal yield <15 (HR, 1.98; 95% CI, 1.29-3.04; P = .002), and elevated LNR (HR, 8.16; 95% CI, 2.89-23.06; P < .001) predicted survival. MIE had higher nodal yields compared with open procedures (30.7 vs 25.3, P < .001). Patients undergoing neoadjuvant chemoradiotherapy had lower nodal yields compared with those with no neoadjuvant therapy and those with neoadjuvant chemotherapy (26.4 vs 30.6 vs 36.8, respectively; P < .001). Regression analysis determined a LNR of <0.05 was associated with a survival benefit.
Textbook lymphadenectomy is associated with improved survival. Low lymph node yield and a high LNR are associated with reduced overall survival. A LNR of <0.05 is associated with significant survival benefit. A minimum nodal yield of 15 should remain the standard of care.
新辅助治疗后的手术切除仍然是治疗食管腺癌的基石，并且经常用于治疗鳞状细胞癌。淋巴结清扫的最佳范围以及增加淋巴结数量是否能带来生存获益尚不清楚。指南建议在食管癌切除术中至少切除和检查 15 个淋巴结。本研究评估了淋巴结产量和淋巴结比率（LNR）对生存的影响，确定了影响淋巴结产量和切除根治性的因素。
回顾 2010 年 1 月 1 日至 2020 年 12 月 31 日期间在一家机构接受根治性食管癌切除术的所有患者。分析了临床和病理变量。LNR 通过将阳性淋巴结数除以切除的总淋巴结数来计算。
共行食管癌切除术 397 例，其中 288 例行微创食管癌切除术（MIE）。切缘状态（危险比[HR]，1.80；95%置信区间[CI]，1.15-2.83；P<.01）、淋巴结产量<15（HR，1.98；95%CI，1.29-3.04；P=.002）和升高的 LNR（HR，8.16；95%CI，2.89-23.06；P<.001）预测生存。MIE 组的淋巴结产量明显高于开放手术组（30.7 对 25.3，P<.001）。与未行新辅助放化疗的患者相比，行新辅助放化疗的患者的淋巴结产量较低，与单纯行新辅助化疗的患者相比，淋巴结产量也较低（分别为 26.4 对 30.6 对 36.8；P<.001）。回归分析确定 LNR<0.05 与生存获益相关。
标准的淋巴结清扫与生存改善相关。低淋巴结产量和高 LNR 与总生存率降低相关。LNR<0.05 与显著的生存获益相关。至少 15 个淋巴结的最低产量应作为标准治疗。
