고려대학교 구로병원 김현구 Two vs. Three Field Lymph Node Dissection in Surgery for...
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Transcript of 고려대학교 구로병원 김현구 Two vs. Three Field Lymph Node Dissection in Surgery for...
고려대학교 구로병원 김현구
Two vs. Three Field Lymph Node Dissection in Surgery for
Esophageal Cancer
Incision vs. LN Dissection
Ivor-Lewis Two-holeTwo-inci-sion
Two-field
McKweon Three-hole Tri-inci-sion
Three-field
Case-1
M/61G-fiber: 39cm from incisorBiopsy: Squamous cell carci-nomaStage: cT1N0M0
Treatment?
Case-2
M/63G-fiber: 25~28cm from incisorBiopsy: severe dysplasia with leiomyomaStage: cT1N0M0
Treatment?
Case-3
M/49G-fiber: 26~28cm from incisorBiopsy: Squamous cell carci-nomaStage: cT1N0M0
Treatment?
Two-Field or Three-Field ?
Tumor locationDepth of tumor inva-sionTumor cell type
Substantial morbidityPrognostic benefitQuality of life
Tumor locationDepth of tumor inva-sionTumor cell type
Optimal Surgical Extent ?
• Systemic dis-ease
• Palliative• Advancement
of
chemotherapy &
radiotherapy
Minimal
• Advancement of
operative tech-nique• Advancement
of
perioperative
management
Radical
Categorization of Esophageal Seg-ment
Cervical
Upper thoracic
Mid thoracic
Lower thoracic
Abdominal
Lymphatic Drainage
Multidirectional lymphatic flow
Lymphatic Drainage
Regional lymphatics (N1)
Submocosal plexusRegional (N1) & non-regional lymph nodes (M1a & M1b)
Thoracic duct & thesystemic venous circula-tion (M1b)
Abundant lymph-capillary network in the submucosal longitudinal lymphatic drainage (vs. segmental in colon ca.) Rice TW, Lancet, 1999, Hosch SB, JCO,
2001, Lerut, Ann Surg, 2004
Lymph-capillary network in submucosal space
☞Widespread and random patterns of lymph node metastasis Ando N, Ann Surg, 2000
Skip metastasis: 50~60% MatsubaraT, Cancer, 2000
Lymph Node Mapping System
Lymph Node Mapping System
N Regional Lymph Nodes
NX Regional lymph nodes cannot be assessed.
NO No regional lymph node metastases
N1 Regional lymph node metastases
M Distant Metastasis
MX Distant metastases cannot be assessed.
M1a: Upper thoracic esophagus metastatic to cervical lymph nodes
Lower thoracic esophagus metastatic to celiac lymph nodes
M1b Upper thoracic esophagus metastatic to other nonregional lymph nodes or
other distant sites
Midthoracic esophagus metastatic to either nonregional lymph nodes or
other distant sites
Lower thoracic esophagus metastatic to other nonregional lymph nodes or
other distant sites
Patterns of Metastatic Nodal Spread
Association with tumor loca-tion-1
Akiyama H, Ann Surg 1994. Altorki N, Ann Surg 2002
Patterns of Metastatic Nodal Spread
☞ 3-field LN dissec-tion
Association with tumor location-2
Kato H, J Surg Oncol 1991
Sharma S, Surg Today 1994
Patterns of Metastatic Nodal Spread
☞ 2-field LN dissec-tion
Nodal metastasis is a rare find-ing three levels away from the location of the tumor. It is most common in the same level as the tumor and one level adja-cent to the tumor. The involve-ment of lymph nodes that are two levels away from the loca-tion of the tumor is also very common but to a lesser extent.
Patients with carcinoma in the upper thoracic esophagus rarely had metastasis in the abdominal nodes, while those with carci-noma in the lower thoracic esophagus rarely had metastasis in the cervical nodes.
Association with depth of tumor inva-sion-1
Rice TW, Ann Thorac Surg 1998
Patterns of Metastatic Nodal Spread
Association with depth of tumor inva-sion-2
Matsubara T, Br J Surg 1999
Patterns of Metastatic Nodal Spread
☞ T stage ↑→ LN Metasta-sis↑
Association with tumor cell type
Sheids 6th edi-tion
Patterns of Metastatic Nodal Spread
☞ No difference
Axial margin
Siu KF, Ann Surg 1986 Law S, Am J Surg 1998
Extent of Resection
Taking account shrinkage of the specimen after resection as a guide to surgery, an in-situ margin of 10cm (fresh contracted specimen of ~5cm) should be aimed to, allow a less than 5% chance of anas-tomotic recurrence.
Lymphadenectomy
Pearson, 3rd edi-tion
Extent of Resection
Standard2-field
Extended2-field
Total2-field
Mediastinal lymph node dissection
Abdominal lymph node dissection
Cervical lymph node dissection
or
Cervical Esophagus
Distant metastasis: 20%Regional metastasis: 63%Median survival: 11~14months5-year survival: 14~21%5-year survival was significantly low when re-gional neck LN involved (8% vs. 38%)
However, regional LN involvement was not prognostic parameter in multivariate analysis
Marmuse JP, Am J Surg, 1995Triboulet JP, Arch Surg, 2001
Upper Thoracic Esophagus
In resectable T3 squamous cell carcinoma,
Manshanden CG Eur J Surg Oncol 2000Igaki H, Br J Surg 2005
☞ Although cervical lymph node dissection is important for staging, curative surgery for cervical-upper esophageal cancer combined with extended lymph node dissection is probably only indicated in selected cases without distant lymph node metastasis.
Bresadola F, ORL J Otorhinolaryngol Relat Spec 2001
o
No differ-ence
Limited resec-tion
Ex-tended LN dis-section
3-year survival
14%
20%
Middle & Lower Thoracic Esophagus
In Japan, 70% of the esophageal carcinoma occurs in the middle tho-racic esophagus.
Ando N, Ann Surg 2000
Tachibana M, Am J Surg 2005Nine of 141 patients with middle esophageal cancer had cervico-tho-racic nodal involvement.→3-field LN dissection proved to be important for correct staging.
In lower thoracic esophageal carcinoma, no patient had cervico-up-per thoracic LN involvement.→ Patients with negative upper thoracic LN not necessarily have to undergo a 3-field LN dissection.
Involved celiac nodes were found in tumors at all three locations.→ For esophageal tumors investigation of celiac LN is worthwhile.
Cervical LN Metastasis in Esophageal Cancer
1. 14~30% patients: metastasis to cervical lymph nodes40% for upper third tumors20% for lower third tumors
2. Frequency of nodal metastasis: increased with depth of tumor penetration
Intramucosa < submucosa < muscularis propria < adventitia 30% < 50% < 60% < 80%
3. LNs in both recurrent laryngeal nerves frequently have metastasis.
Isono K, 1991, Oncology
☞ Extended radical esophagectomy with 3-field LN dissection☞ Improving accuracy of staging & better local control
5 –Year Survival in 2- vs. 3-Field LN Dissection
Akiyama H, Am J Surg. 1984
2-Field 3-Field p
- Node 55% 84% 0.004
+ Node 28% 43% 0.008
Skeptical Views to 3-Field LN Dis-section-1
1. Systemic disease Replaced by neoadjuvant chemotherapy or intraoperative radiother-
apy
2. Hospital mortality: 4% Increased morbidity: 44.8% Recurrent laryngeal nerve palsy: 16~58% Pulmonary complication: 21.3% Anastomotic leak: 19~30% Septic complication: 27%
Decreased QOL Severe hoarseness, restricted food intake, reduced exercise tolerance:
20%
Skeptical Views to 3-Field LN Dis-section-2
3. No prognostic benefit Recurrence rate in cervical LN: 11% Isolated cervical nodal recurrence: 4% vs. Mediastinum(21%), systemic organ metastasis(26%) ☞ Minimal role of cervical LN dissection
4. Prospective Randomized study
2-Field 3-Field p
Nishihira T, Am J Surg, 1998
48% 65% NS
National cancer hos-pital in Tokyo
33% 48% 0.3
LN Dissection along Recurrent Laryn-geal Nerve
Recurrent laryngeal LN + cervical LN → Cervicothoracic group
Selective 3-Field LN Dissec-tion
Sentinel Lymph Node
The first lymph node within the lymphatic basin reached by lymph draining from the primary lesion
Limited Reports
Complicated compared to gastric cancer
Limited No. of early esophageal can-cer
The frequency of metastasis in SLN was significantly higherLN involvement was found in only 2% of the non-SLN
Kitagawa Y, Surg Clin North Am 2000
The preoperative mapping of SLN based on the lym-phoscintigraphy Improved the accuracy of the intraoperative gamma probing
Baciewicz FA, Jr., J Invest Surg 2000
Procedure Preoperation
1 day before surgeryRadioisotope injec-
tion
4 hours after injec-tion
Lymphoscintigram
Kitagawa, Gen Thorac Cardiovasc Surg, 2008
Procedure Intraoperation
Percutaneous gamma prob-ing
Gamma probing through thoracotomy or thora-
coscopy
Dual tracer methodRadioisotope Blue dye: endoscopically in-
jection right before surgery
SLN Mapping in Esophageal Cancer
1. Predict overall lymph node status
2. Tailored extent of lymphadenectomy Avoid unnecessery morbidity and mortality for node- negative patientsMore radical treatment for node-positive patients
3. More detailed examination to optimize disease staging of target specific nodal tissue
Step sectioningImmunochemistryRT-PCR
4. Determination of the radiation field during CCTR
SLN Mapping in EMR
Organ preservation treatment: EMR, PDT, Argon plasma coagulation
KUGH Experiences
Sex
Age Location CCRT C-StageP-
StageOperation SLN
No. of SLN
Metastasis
M 65 Lower NoT1N0M
0T3N1M
0Ivor-Lewis 8, 17, 20 3 17
F 56 Lower NoT1N0M
0T3N0M
0Ivor-Lewis 9 1 no
M 64 Lower NoT1N0M
0T1N0M
0Ivor-Lewis 7, 8, 10, 17 4 no
M 64 Middle YesT1N0M
0T0N0M
0McKeown 3p 1 no
M 65 Lower NoT1N0M
0T3N0M
0Left
thoracotomy17, 18 2 no
M 61 Lower NoT1N0M
0T2N0M
0Ivor-Lewis 20 1 no
M 48 Middle YesT3N0M
0T0N0M
0Ivor-Lewis 4 1 no
M 60 Upper YesT2N0M
0T2N0M
0McKeown 1, 8, 9 3 no
M 70 Middle NoT2N0M
0T3N1M
0McGweon 1, 2, 4, 7, 8 5 2
M 65 Middle NoT1N0M
0T2N0M
0McGweon 1, 7 2 no
M 46 Middle NoT2N0M
0T2N0M
0McGweon 7, 8 2 no
M 50 Lower NoT2N0M
0T2N1M
0Ivor-Lewis
7, 8, 9, 16, 18
5 16
M 58 Lower NoT2N0M
0T3N1M
0Ivor-Lewis 7 1 16
Duration: November 2007 ~ March 2009Patients: T1~3 N0M0 squamous esophageal cancerRadioisotope: 99mTc-neomannosyl human serum albumin (99mTc-MSA)
Results
No. of sentinel lymph node 2.4±1.50 (1~5)
Detection rate 100%
False-negative SLN 1/ 13 (7.7%)
Conclusions
Curative surgery for cervical-upper esophageal cancer com-bined with extended LN dissection is probably only indicated in selected cases without distant LN metastasis.
3-field LN dissection proved to be important for correct stag-ing in middle esophageal cancer.
In lower thoracic esophageal carcinoma, patients with nega-tive upper thoracic LN not necessarily have to undergo a 3-field LN dissection.
No statistical difference in survival was found in randomized trials comparing an extensive LN dissection with a limited lymphadenectomy.
Selective LN dissection using sentinel lymph node mapping have to be further evaluated before it can be applied widely.
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