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Three-field vs two-field lymphadenectomy in thoracic ESCC patients: a multicenter randomized study (NST 1503).
Yousheng Mao1, Shuoyan Liu2, Yongtao Han3
1Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
Omitting three-field lymph node dissection (3FL) is safe for patients with resectable thoracic esophageal squamous cell cancer and negative right recurrent laryngeal nerve lymph nodes. This approach avoids unnecessary complications while maintaining comparable survival outcomes.
Area of Science:
- Oncology
- Surgical Oncology
- Thoracic Surgery
Background:
- Three-field lymph node dissection (3FL) is associated with higher perioperative complications compared to two-field lymph node dissection (2FL).
- Determining if 3FL can be omitted in specific esophageal cancer patient groups is crucial for improving surgical outcomes.
- Right recurrent laryngeal nerve lymph nodes (RRLN-LNs) status is a key factor in guiding lymphadenectomy extent.
Purpose of the Study:
- To evaluate if three-field lymph node dissection (3FL) can be omitted in resectable thoracic esophageal squamous cell cancer (ESCC) patients with negative RRLN-LNs without compromising overall survival (OS) and disease-free survival (DFS).
- To compare the oncological outcomes and complication rates between different lymphadenectomy strategies based on RRLN-LN status.
Main Methods:
- A non-inferiority trial involving patients with cT1b-3N0-1M0 thoracic ESCC undergoing McKeown esophagectomy.
- Patients were stratified based on frozen section examination of RRLN-LNs: positive RRLN-LNs led to direct 3FL, while negative RRLN-LNs were randomized to 2FL or 3FL.
- A total of 829 patients were recruited, with 121 having positive RRLN-LNs and 766 randomized after negative RRLN-LN assessment.
Main Results:
- The cervical lymph node metastasis rate was significantly higher in the positive RRLN-LN group (28.9%) compared to the negative RRLN-LN 3FL group (8.3%).
- Five-year OS and DFS were comparable between the negative RRLN-LN 2FL (68.8% OS, 62.8% DFS) and 3FL (72.2% OS, 65.1% DFS) groups.
- Outcomes in the positive RRLN-LN 3FL group (50.3% OS, 41.2% DFS) were significantly worse than in the negative RRLN-LN groups.
Conclusions:
- Upfront surgery with frozen section analysis allows for the avoidance of additional cervical lymphadenectomy in patients with middle or lower thoracic ESCC and negative RRLN-LNs.
- Omitting 3FL in selected ESCC patients with negative RRLN-LNs is oncologically safe and reduces perioperative complications.
- Frozen section of RRLN-LNs is a valuable tool for tailoring lymphadenectomy extent in thoracic ESCC surgery.
