En-bloc esophagectomy with three
field lymph node dissection is a
superior oncologic procedure
Nasser K. Altorki, M.D.Professor of Cardiothoracic Surgery
Department of Cardiothoracic Surgery
Minimal access surgery : a transformative event in
surgical sciences
Minimal access surgery for malignant disease : a
work in progress
Access alone is not sufficient
En-bloc resection : the importance of radial margins
Standard En bloc
Circumferential Resection Margins in Esophageal
Carcinoma
Pultrum et al. Ann.surg.Onc. 2010
Circumferential Resection Margins in Esophageal
Carcinoma
� 98 TT resections
� CRM
-ve : >1mm
Pultrum et al, Ann. Surg. Oncol, 2010
+ve ≤ 0-1 mm
� CRM +ve :
48% ( 83% in T-3 )
� LR:
68% vs 25% (p=0.002)
Posterior Mediastinectomy
Mobilized Specimen
Lymphatic drainage of the esophagus
Yajin et al, JTCVS, 2009
Nodal site total
neck 13/23
Detection of ferumoxide-positive LN in 23 T1 Sq.Ca
Mapping esophageal lymph drainage by paramagnetic iron
nano-particle enhanced MRI
neck 13/23
(57%)
recurrent 15/23
(65%)
abdomen 20/23
(87%)
Motoyama, Surgery 2007Harisingani MG, NEJM, 2003
Recurrent nodal metastases : an early event
Nodal Group pts w +ve nodesExclusive
involvement
Deep cervical 4 1 (25%)
Nodal metastases in 43/110 superficial sq. carcinoma
Rec. nerve 24 17 (70%)
Intrathoracic 9 3 (33%)
Perigastric 18 12 (66%)
Matsubara, BJS 1999
T-status Positive nodes percent +ve Cx nodes percent
T1 8/24 33% 5/24 21%
Recurrent nodal metastases : an early event
T2 17/24 71% 4/24 16.6%
T3 96/123 78% 32/123 26%
T4 1/2 50% 0/2 0
Lerut et al, Ann. Surg. 2004
Third Field (sup.mediastinum)
Third Field (sup.mediastinum)
The neck dissection
Prognostic Factors for Positive CRL nodes
Factor SubgroupNumber
patients
Positive CRL
nodesP-value
Histology
Squamous cell 55 36%
0.02
Adenocarcinoma 130 20%
Location
Middle 37 38%
0.04
Lower / GEJ 148 22%
Induction therapyNo 90 24%
NSYes 95 24%
Prognostic Factors for Positive CRL nodes
Factor SubgroupNumber
patients
Positive CRL
nodesP-value
Clinical T
classification
cT0-2 42 17%
0.04
cT3-4 118 33%
pN classification
N0 55 0%
<0.001
N1 42 17%
N2 45 38%
N3 43 51%
ability
1 . 0 0
. 7 5
. 5 0
Overall Survival (N=140)
Su rviva l (m on t h s )
1 6 81 441 2 09 67 24 82 40
Proba . 5 0
. 2 5
. 0 0
0 . 4 0
Overall Survival:
± CRL nodes
Overall 5 year survival:
No CRL nodes: 44.8%
Positive CRL nodes: 24.9%
Radical 3-Field Enbloc Esophagectomy
�Feasible with low mortality (2%).
�Local recurrence < 5%.
�Ten year survival : 40%.
�Cervical nodal metastasis occurs in 25% �
of patients.
�Prolonged survival may be possible in advanced disease especially in
patients with squamous cell carcinoma.
�Over 50% of patients still succumb to systemic disease demonstrating
the need for novel and better systemic therapy.
Total Number of LNs and Survival:
Analysis of the SEER Database
Median # resected nodes: 8
Median # +ve nodes: 1
Schwarz et al, J Gastrointest. Surg. 2007
Median # +ve nodes: 1
Resected Nodes in ACOSOG Z0060
Esophagectomy 134 pts.
Resected nodes 11 nodes
45% had ≤10 nodes removed 45% had ≤10 nodes removed
Thoracotomy 13 nodes
THE 9 nodes
Veeramachanini, Ann.Thorac. Surg, 2008)
Extended Transthoracic Resection
vs Transhiatal Resection: DFS
39%
Hulscher et al, NEJM, 2002
29%
