Extent of Lymphadenectomy and Prognosis After Esophageal Cancer Surgery.
OBJECTIVE
The prognostic role of the extent of lymphadenectomy during surgery for esophageal cancer is uncertain and requires clarification.


OBJECTIVE
To clarify whether the number of removed lymph nodes influences mortality following surgery for esophageal cancer.


METHODS
Conducted from January 1, 2000, to January 31, 2014, this was a cohort study of patients who underwent esophagectomy for cancer in 2000-2012 at a high-volume hospital for esophageal cancer surgery, with follow-up until 2014.


METHODS
The main exposure was the number of resected lymph nodes. Secondary exposures were the number of metastatic lymph nodes and positive to negative lymph node ratio.


METHODS
The independent role of the extent of lymphadenectomy in relation to all-cause and disease-specific 5-year mortality was analyzed using Cox proportional hazard regression models, providing hazard ratios (HRs) with 95% CIs. The HRs were adjusted for age, pathological T category, tumor differentiation, margin status, calendar period of surgery, and response to preoperative chemotherapy.


RESULTS
Among 606 included patients, 506 (83.5%) had adenocarcinoma of the esophagus, 323 (53%) died within 5 years of surgery, and 235 (39%) died of tumor recurrence. The extent of lymphadenectomy was not statistically significantly associated with all-cause or disease-specific mortality, independent of the categorization of lymphadenectomy or stratification for T category, calendar period, or chemotherapy. Patients in the fourth quartile of the number of removed nodes (21-52 nodes) did not demonstrate a statistically significant reduction in all-cause 5-year mortality compared with those in the lowest quartile (0-10 nodes) (HR, 0.86; 95% CI, 0.63-1.17), particularly not in the most recent calendar period (HR, 0.98; 95% CI, 0.57-1.66 for years 2007-2012). A greater number of metastatic nodes and a higher positive to negative node ratio was associated with increased mortality rates, and these associations showed dose-response associations.


CONCLUSIONS
This study indicated that the extent of lymphadenectomy during surgery for esophageal cancer might not influence 5-year all-cause or disease-specific survival. These results challenge current clinical guidelines.
Upper Gastrointestinal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, England2Section of Gastrointestinal Cancer, Division of Cancer Studies, King's College London, London, England3Upper Gastrointestinal Surgery, Department of Molecular Medic.
Jesper
J
Lagergren
Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
Fredrik
F
Mattsson
Upper Gastrointestinal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, England2Section of Gastrointestinal Cancer, Division of Cancer Studies, King's College London, London, England3Upper Gastrointestinal Surgery, Department of Molecular Medic.
Janine
J
Zylstra
Section of Gastrointestinal Cancer, Division of Cancer Studies, King's College London, London, England.
Fuju
F
Chang
Upper Gastrointestinal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, England2Section of Gastrointestinal Cancer, Division of Cancer Studies, King's College London, London, England3Upper Gastrointestinal Surgery, Department of Molecular Medic.
James
J
Gossage
Upper Gastrointestinal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, England2Section of Gastrointestinal Cancer, Division of Cancer Studies, King's College London, London, England3Upper Gastrointestinal Surgery, Department of Molecular Medic.
Robert
R
Mason
Section of Gastrointestinal Cancer, Division of Cancer Studies, King's College London, London, England4Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
Pernilla
P
Lagergren
Upper Gastrointestinal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, England2Section of Gastrointestinal Cancer, Division of Cancer Studies, King's College London, London, England3Upper Gastrointestinal Surgery, Department of Molecular Medic.
Andrew
A
Davies
D000230:Adenocarcinoma / Q000401:mortality / Q000601:surgery; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002294:Carcinoma, Squamous Cell / Q000401:mortality / Q000601:surgery; D015331:Cohort Studies; D004938:Esophageal Neoplasms / Q000401:mortality* / Q000601:surgery*; D016629:Esophagectomy; D005500:Follow-Up Studies; D006801:Humans; D008131:London / Q000453:epidemiology; D008197:Lymph Node Excision; D008198:Lymph Nodes / Q000473:pathology / Q000601:surgery; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000401:mortality; D011379:Prognosis; D016016:Proportional Hazards Models