Post-Oesophagectomy Survival Independent of Lymphadenectomy Extent

Increasing the number of lymph nodes removed does not improve oesophageal cancer patient survival after surgery

medwireNews: Extent of lymphadenectomy does not predict patient survival after oesophagectomy, suggests research published in JAMA Surgery.

The study of 606 oesophageal cancer patients treated at a high-volume hospital in London, UK, between 2000 and 2012 found no relation between the number of lymph nodes removed and 5-year all-cause mortality or disease-specific mortality.

Patients had up to 52 lymph nodes removed but no significant correlation was detected, regardless of whether patients were grouped by decile or quartile for lymph nodes removed, or after adjusting for confounding factors, such as age, tumour stage and response to preoperative chemotherapy.

By contrast, there was a “strong” dose–response relationship between the number of metastatic lymph nodes and both all-cause and disease-specific mortality, with adjusted hazard ratios (HRs) of 3.48 and 3.84, respectively, for patients with six or more positive nodes compared with zero nodes.

Similarly, the ratio of positive nodes to total number of nodes significantly predicted the two survival measures, with corresponding adjusted HRs of 4.12 and 4.64 for ratios greater than 0.37 versus a ratio of 0.

“These results challenge clinical guidelines recommending 2-field lymphadenectomy”, say Jesper Lagergren, from Guy’s and St Thomas’ NHS Foundation Trust in London, UK, and co-authors.

While recommending research to directly compare the impact of wide versus standard lymph node excision in oesophageal cancer, the authors note that studies have shown that more extensive lymphadenectomy has increased morbidity without improving mortality in breast cancer patients.

“As a result, a less extensive and more tailored approach to lymphadenectomy has been adopted,” they observe, with similar trends also cited for endometrial cancer and for some gastrointestinal malignancies.

In an accompanying comment, Marco Patti, from the University of Chicago in Illinois, USA, agrees that the current study challenges the standard of care and queries whether extensive lymphadenectomy improves survival or “just [allows] for better staging and migration?”

He suggests that “it is not the operation we perform that makes a difference but rather the tumor biology and the stage of the tumor at the time the operation is performed”, and recommends: “Until a definitive answer is given, surgeons should perform either a transhiatal or a transthoracic esophagectomy based on the patient’s status and their own preference.”

Reference

Lagergren J, Mattsson F, Zylstra J, et al. Extent of lymphadenectomy and prognosis after esophageal cancer surgery. JAMA Surg 2015; Advance online publication 2 September. doi:10.1001/jamasurg.2015.2611

Patti MG. Survival after lymphadenectomy in patients with esophageal cancer. A controversial issue. JAMA Surg 2015; Advance online publication 2 September. doi:10.1001/jamasurg.2015.2599

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