Pattern of recurrence following radical oesophagectomy with two-field lymphadenectomy

Despite increasingly radical surgery for oesophageal cancer, many patients continue to develop recurrent disease. The aim of this study was to evaluate the pattern of failure following attempted curative oesophagectomy with two-field lymphadenectomy for adenocarcinoma and squamous cell carcinoma of the middle and lower third of the oesophagus.

A total of 176 consecutive patients discharged from hospital following R0 resection between 1 April 1990 and 31 December 1999 were followed for evidence of recurrence over a mean interval of 26 months.

Adenocarcinoma was the predominant histological subtype (n = 113) compared with squamous cell carcinoma (n = 63). Sex and age distribution were similar for both histological subtypes (M:F ratio 2.5:1, median age 64 (range 40-77) years). Overall 2- and 5-year survival rates were 54 and 31 per cent respectively. Some 85 patients (48 per cent) developed proven recurrence, of whom five are alive and 80 dead. The median time to recurrence was 11.7 (range 1. 5-67) months, with a median survival thereafter of only 2.7 (0-25.9) months. The pattern of recurrence was locoregional in 27 per cent (mediastinal 21 per cent and cervical 6 per cent) and distant in 18 per cent (liver 6 per cent, bone 6 per cent, cerebral 2 per cent, peritoneal 2 per cent, lung 1 per cent, skin 1 per cent). There was no difference in the overall pattern of dissemination or timing of recurrence for either histological subtype. Over 50 per cent of all recurrences occurred within 12 months of surgery, with local, regional and distant recurrence occurring at a median of 11.9 (range 1.8-52), 11.0 (range 5-67) and 11.0 (1.5-58) months respectively.

The low incidence of cervical recurrence suggests that a more extensive 'three-field' lymphadenectomy is unlikely to improve survival rates. Better staging modalities are needed to identify patients who will have recurrence within 12 months of operation, so that they may be either entered into trials of multimodality treatment or offered non-surgical palliation. British Journal of Surgery prize-winning paper, presented to the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, London, UK, September 1999