Extent of Lymphadenectomy in Esophageal Cancer Surgery: Unresolved Issues in Prophylactic 3-Field Dissection

Area of Science:

• Surgical Oncology
• Gastrointestinal Surgery
• Thoracic Surgery

Background:

• Esophagectomy with lymphadenectomy is crucial for esophageal cancer treatment.
• The extent of lymphadenectomy, specifically 2-field (2FL) vs. 3-field (3FL), remains debated due to lymphatic spread.
• Inconsistent definitions historically complicate evidence interpretation.

Purpose of the Study:

• To review the historical evolution and current perspectives on lymphadenectomy extent in esophageal cancer.
• To clarify the definitions of 2FL and 3FL and their impact on research interpretation.
• To evaluate the evidence for 3FL versus 2FL in resectable esophageal cancer.

Main Methods:

• Literature review summarizing historical development and current evidence.
• Analysis of evolving definitions of 2FL and 3FL in the Japanese Classification of Esophageal Cancer.
• Examination of recent meta-analyses and multicenter retrospective studies.

Main Results:

• Previous studies used varied definitions of 2FL, hindering direct comparison with 3FL.
• Current definitions: 2FL includes cervical nodes; 3FL adds supraclavicular nodes.
• Recent evidence shows no clear survival advantage for prophylactic 3FL over contemporary 2FL.

Conclusions:

• Precise understanding of lymphadenectomy definitions is vital for interpreting esophageal cancer surgery literature.
• Current Japanese guidelines weakly recommend 3FL for upper/middle thoracic tumors.
• The JCOG2013 trial will further clarify the role of prophylactic supraclavicular lymph node dissection.