Selective three-field lymphadenectomy for thoracic esophageal squamous carcinoma

The purpose of this study was to examine metastasis in different nodal stations and the extent of lymphadenectomy for esophageal carcinoma. Eighty-seven thoracic esophageal squamous carcinoma patients underwent esophagectomy with two-field or three-field lymphadenectomy based on cervical ultrasonography. Thirty-five patients (40.2%) with ultrasonography-detected cervical nodes underwent cervical dissection. Significantly more patients with primary tumors in the upper thoracic esophagus had cervical dissection than patients with tumors in the middle and lower esophagus (66.7%vs. 30.2%, P=0.002). Metastasis to cervical, superior mediastinal, mid-mediastinal, and abdominal nodes were 19.5%, 25.3%, 23%, and 24.1%, respectively. Cervical metastasis was 29.2%, 20.8%, and 10% for upper, middle, and lower thoracic esophageal tumors. Regional lymphadenopathy was found in 48 patients (55.2%) and was significantly related to cervical metastasis (31.3%vs. 5.1%, P=0.002). It was significantly less in upper (37.5%) than in middle (62.3%) and lower (60%) thoracic esophageal tumors (P=0.041). When cervical metastasis was included into regional lymphadenopathy, the difference was no longer significant (45.8%vs. 63.5%, P=0.135). Cervical dissection was associated with significantly more morbidities (60%vs. 34.6%, P=0.020), especially recurrent laryngeal nerve palsy (22.9%vs. 9.6%, P=0.089). Recurrent laryngeal nerve palsy was related significantly to anastomotic leakage (53.8%vs. 13.5%, P=0.001). There was no significant difference between the 2-year survivals for patients with or without cervical metastasis (50.0 vs. 72.0%, P=0.094). We conclude that cervical metastasis is of a similar rate as metastasis to mediastinal or abdominal nodes. Cervical nodes should be taken as regional lymph nodes for thoracic esophageal cancer. Cervical dissection is associated with increased morbidity and should be reserved for patients who may benefit from the procedure. Selective three-field dissection based on ultrasonography is helpful in reducing surgical morbidity while increasing the completeness of resection.