ASO Author Reflections: Achieving Adequate Lymphadenectomy in Esophageal Cancer Resection
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Achieving Adequate Lymphadenectomy in Esophageal Cancer Resection Cary Jo R. Schlick, MD1, and David J. Bentrem, MD MS1,2 1
Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; 2Surgery Service, Jesse Brown VA Medical Center, Chicago, IL
PAST
PRESENT
Esophageal cancer has a poor overall survival and complex treatment algorithms that may include chemotherapy, radiation, and/or surgical resection. Given the multifaceted nature of esophageal cancer treatment, there has been an evolving focus on quality measure development and adherence in this field. The National Comprehensive Cancer Network (NCCN) has provided guidance surrounding quality cancer care and has advocated for adequate lymphadenectomy, defined as evaluation of at least 15 lymph nodes, during esophageal cancer resections.1 Adequate lymphadenectomy is important for accurate staging of esophageal cancer and is associated with improved survival, likely as a result of improved staging accuracy.2 However, these data are based upon primary surgical resection for esophageal cancer, and prior studies have advocated for varying lymphadenectomy thresholds following neoadjuvant therapy.3 Arguments for different lymphadenectomy thresholds are rooted in theories that neoadjuvant therapy causes fibrosis which changes the surgical technique, or alternatively lymphocyte depletion, decreased lymph node size, and difficulty with pathologic evaluation.4
We were concerned that providers may be complacent with inadequate lymphadenectomy following neoadjuvant therapy given the theories posed above, despite the demonstrated importance of adequate lymphadenectomy in high quality esophageal cancer care. Thus, we sought to determine whether an association exists between neoadjuvant therapy use and other treatment decisions with achieving adequate lymphadenectomy.5 Based on surgically treated esophageal cancer patients in the National Cancer Database (NCDB), adequate lymphadenectomy rates were 40.6% overall, and have improved over time, with 52.6% of patients having adequate lymphadenectomy in 2015. There was no difference in adequate lymphadenectomy rates based upon the use of neoadjuvant therapy on bivariate or adjusted analyses. However, patients who underwent minimally invasive esophagectomy (either laparoscopic or robotic) were more likely to have an adequate lymphadenectomy than those who underwent open esophagectomy. Likewise, patients treated at high volume centers were more likely to have adequate lymphadenectomy than those treated at low volume centers. FUTURE
Ó Society of Surgical Oncology 2020 First Received: 23 March 2020 C. J. R. Schlick, MD e-mail: [email protected]
Despite increases in adequate lymphadenectomy rates over time, only half of the patients undergoing esophagectomy for malignancy have an adequate lymphadenectomy. Based on this study, patients who receive neoadjuvant therapy are just as likely to
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