[Tumors of the upper gastro-intestinal tract]

The appropriate extent of lymph node dissection in tumors of the upper gastro-intestinal tract continues to be debated. The basic tenet of surgical oncology that cancerous lymph nodes are indicators not governors of survival is under question and derives from the different theories of metastasis. Is the metastatic flow linear (indicators) or does it occur in parallel to tumorigenesis (governor)? If the latter theory is true there would be only a limited indication for lymphadenectomy (LA).Extended LA leads to an ameliorated staging of the N category. Following LA locoregional tumor control is significantly improved for esophageal and gastric cancer. In case of gastric cancer it is evident that there is a group of patients in which extended LA lead to improved long-term survival. This gain in prognosis affects patients in which lymph node metastasis is not or only slightly advanced. In locally advanced tumors there is no prognostic benefit. Patients who might benefit from the extended procedure cannot be assessed during preoperative staging. Therefore, the indications for the procedure should be liberally carried out by experienced hands and in experienced centers. According to randomized studies there is no indication for extended radical LA in pancreatic cancer.