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Extent of lymphadenectomy may not influence survival in esophageal cancer
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The number of lymph nodes removed during lymphadenectomy may not influence 5-year all-cause or disease-specific survival among patients with esophageal cancer, according to the results of a cohort study.
These study findings diverge from the current clinical practice guidelines, according to the researchers. Because metastatic lymph nodes are the strongest known prognostic factors, it had been believed that extensive lymphadenectomy improved survival outcomes.
“Although based on a limited number of studies with methodological concerns with stage migration and confounding, current clinical guidelines recommend 2-field (extensive) lymphadenectomy,” Jesper Lagergren, MD, PhD, professor and chair of upper gastrointestinal cancer at King’s College London and honorary consultant of surgery at Guy’s and St. Thomas’ Trust, and colleagues wrote. “Yet, in routine clinical practice, the limited scientific knowledge leaves it up to the discretion of the individual surgeon to decide the preferred extent of lymphadenectomy. The present study was prompted by the lack of survival benefit from a more extensive lymphadenectomy in our population-based Swedish cohort study [van der Schaaf M, et al. J Natl Cancer Inst. 2015;doi:10.1093/jnci/djv043.].”
Lagergren and colleagues conducted a cohort study to determine whether the number of lymph nodes removed influenced post-surgical mortality. The analysis included 606 patients (median age, 64 years; range, 29-83) undergoing esophagectomy at St. Thomas’ Hospital in London between 2000 and 2012, with follow-up conducted until 2014. Most patients (83.5%; n = 506) had adenocarcinoma of the esophagus.
The role of the extent of lymphadenectomy in relation to 5-year all-cause and disease-specific mortality served as the primary endpoint.
Fifty-three percent of patients (n = 323) died within 5 years of surgery, and 39% (n = 235) died of tumor recurrence.
The extent of lymphadenectomy did not reach a statistically significant association with all-cause or disease-specific mortality, independent of calendar period, chemotherapy receipt or the categorization of lymphadenectomy.
Patients with the highest number of removed lymph nodes (21–52 nodes) did not demonstrate a significant reduction in all-cause 5-year mortality compared with patients with the lowest number (0–10) of removed lymph nodes (HR = 0.86; 95% CI, 0.63-1.17). The lack of an association appeared stronger among the most recently treated patients included in the study (HR = 0.98; 95% CI, 0.57-1.66 for patients treated between 2007 and 2012).
However, the researchers observed greater mortality rates among patients with six or more metastatic lymph nodes (HR = 6; 95% CI, 2.83-12.7) and a higher positive to negative node ratio (HR = 7.12; 95% CI, 3.47-14.6).
“The results of this study indicated a need for further research addressing the value of more and less extensive lymphadenectomy (eg, a multisite interventional study comparing wide excision of lymph nodes vs. standard excision),” Lagergren and colleagues wrote. “Yet, it might be justified to compare the results of this study with the developments in lymphadenectomy during surgery for other tumors. In breast cancer, the previously advocated more extensive lymphadenectomy did not improve survival but increased morbidity.”
Surgeons and patients should consider all appropriate factors when choosing curative surgical approaches for esophageal cancer, Marco G. Patti, MD, professor of surgery and director of the Center for Esophageal Diseases at University of Chicago Pritzker School of Medicine, wrote in an accompanying editorial.
“Personally, I think it is not the operation we perform that makes a difference but rather the tumor biology and the stage of the tumor at the time the operation is performed,” Patti wrote. “Until a definitive answer is given, surgeons should perform either a transhiatal or a transthoracic esophagectomy based on the patient’s status and their own preference.” – by Cameron Kelsall
Disclosure: The researchers and Patti report no relevant financial disclosures.
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