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Eur J Cardiothorac Surg 2005;28:506-507
© 2005 Elsevier Science NL

Letter to the Editor

Radical lymphadenectomy in esophageal adenocarcinoma

Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai 400012, India

Received 11 April 2005; accepted 31 May 2005.

^* Corresponding author. Tel.: +91 22 24177000; fax: +91 22 24146937. (Email: cspramesh{at}vsnl.net).

Key Words: Esophagus • Adenocarcinoma • Lymphadenectomy • Extended

We read with interest D'Journo and colleagues' [1] article on the comparison between standard and extended mediastinal lymphadenectomy for esophageal adenocarcinoma. We have several criticisms on the paper. First, the authors' definition of standard and extended lymphadenectomy is at variance with those of the consensus conference of the International Society for Diseases of the Esophagus (ISDE) [2]. The authors' considered lower mediastinal and subcarinal nodes in the mediastinum and paracardial, lesser curvature, celiac and left gastric nodes in the abdomen as ‘standard lymphadenectomy’ and the addition of common hepatic and splenic nodes in the abdomen and right and left superior mediastinal nodes as ‘extended lymphadenectomy’ [1]. In fact, according to the consensus conference definitions [2], there is no difference in the extent of abdominal lymphadenectomy between the standard and extended surgeries. Also, extended lymphadenectomy is actually the addition of the right recurrent, paratracheal and upper paraesophageal nodes to the standard procedure. The addition of right and left superior mediastinal nodes is a ‘total mediastinal lymphadenectomy’.

We are puzzled as to how the authors could perform a bilateral supracarinal nodal dissection after an Ivor Lewis procedure as exposure to the nodal regions, especially the bilateral recurrent laryngeal groups (which are important nodal basins in esophageal cancer), is suboptimal if the entire thoracic esophagus is not dissected. The incidence of recurrent laryngeal nerve paresis is considerable in all series of three field and extensive mediastinal lymph node dissection [2–4]. In this context, the authors' results of zero incidence of recurrent laryngeal paresis are also difficult to accept after extensive lymphadenectomy around the right and especially the left recurrent laryngeal nerves. It either implies inadequate dissection around the recurrent laryngeal nerves (which is likely after an Ivor Lewis procedure) or inadequate attempt to identify paresis in the postoperative period. Were routine laryngoscopies done even in patients with a normal voice postoperatively?

The two groups are also not comparable as two surgeons operated standard procedures, while two different surgeons operated extended procedures. Also, the yield of less than five nodes after standard lymphadenectomy is extremely low and implies inadequate lymphadenectomy. The morbidity of radical lymphadenectomy during esophagectomy is predominantly respiratory (haemorrhage is rarely an issue) and we fail to understand how the authors noticed significantly higher requirement of blood transfusions in the extended group compared to the standard group. We also find it difficult to explain the inordinately high hospital (27 and 30 days) and ICU (8 and 11 days) stay in patients undergoing either type of surgery. We disagree with the authors' conclusion that "...extended lymphadenectomy appears a reasonable compromise between 3-field lymphadenectomy and transhiatal esophagectomy" as their study does not address this issue at all. Current evidence does not clearly demonstrate the superiority of radical lymphadenectomy over standard lymphadenectomy and we have just started a randomized controlled trial in our institute to answer this question.

References

1. D'Journo XB, Doddoli C, Michelet P, Loundou A, Trousse D, Giudicelli R, Fuentes PA, Thomas PA. Transthoracic esophagectomy for adenocarcinoma of the oesophagus: standard versus extended two-field mediastinal lymphadenectomy. Eur J Cardiothor Surg 2005;27:697-704.[Abstract/Free Full Text]
2. Fumagalli U, Akiyama H, DeMeester TR. Resective surgery for cancer of the thoracic esophagus: results of a consensus conference held at the VIth World congress of the international society for diseases of the esophagus. Dis Esophagus 1996;9:30-38.
3. Nishihira T, Hirayama K, Mori S. A prospective randomized trial of extended cervical and superior mediastinal lymphadenectomy for carcinoma of the thoracic esophagus. Am J Surg 1998;175:47-51.[CrossRef][Medline]
4. Baba M, Aikou T, Yoshinaka H, Natsugoe S, Fukumoto T, Shimazu H, Akazawa K. Long term results of subtotal esophagectomy with three field lymphadenectomy for carcinoma of the thoracic esophagus. Ann Surg 1994;219:310-316.[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Pramesh, C.S. Articles by Mistry, R. C. Search for Related Content PubMed PubMed Citation Articles by Pramesh, C.S. Articles by Mistry, R. C. Related Collections Esophagus - cancer