ASO Author Reflections: Risk Factors and Prognostic Impact of Mediastinal Lymph Node Metastases in Patients with Esophag
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Risk Factors and Prognostic Impact of Mediastinal Lymph Node Metastases in Patients with Esophagogastric Junction Cancer Osamu Shiraishi, MD, PhD Department of Surgery, Kindai University, Faculty of Medicine Hospital, Higashio¯saka, Japan
PAST The incidence of esophagogastric junction (EGJ) cancer has increased in Asia and in Western countries in recent decades.1,2 The ideal surgical treatment for true cardia EGJ cancer remains unclear. Randomized, control trials have compared a transthoracic approach (TT) with TH, and one study comparing TT via left thoracotomy with TH showed that overall survival curves were roughly equivalent.3,4 The transthoracic approach is associated with a risk of severe postoperative complications, such as pneumonia, resulting in negative outcomes of mediastinal lymph node (MLN) dissection via this approach. The current risk of treatmentrelated death has decreased with improved perioperative treatment. We suggest that whether surgery is performed with TT should be decided according to the likelihood of MLN metastases in each patient. In our study, we clarified MLN metastasis risk factors in EGJ cancer, including adenocarcinoma (AC) and squamous cell carcinoma (SCC), with an epicenter between 2 cm above and below the EGJ and verified the treatment efficacy by evaluating the prognosis of patients with MLN metastases.5 PRESENT In this retrospective study, 50 patients with EGJ cancer who underwent surgery without preoperative treatment were eligible to participate; 34 patients had AC, and 16 had SCC.5 Twenty-four patients underwent transhiatal
Ó Society of Surgical Oncology 2020 First Received: 13 May 2020; Published Online: 25 May 2020 O. Shiraishi, MD, PhD e-mail: [email protected]
resection, and 26 underwent transthoracic resection. MLN metastasis was observed in 13 patients (26%) regardless of histological type; 9 of these had metastasis in the upper and middle mediastinum. Metastasis occurred when the esophageal invasion length (EIL) exceeded 20 mm. Additionally, 10 of 13 patients (77%) with MLN metastasis had pN2–3 stage cancer. The 5-year overall survival rate was 38% and 65% in the MLN-positive and -negative groups, respectively (p = 0.12). Multivariable Cox regression analysis showed that only stage pN2–3, and not the presence of MLN metastasis, was a significant poor prognostic factor. Our study showed that MLN metastasis was closely associated with EIL, and that EIL \ 20 mm was a risk factor for MLN metastasis. MLN metastasis itself was not a poor prognostic factor, although it tended to occur when patients progressed to pN2-3 and carried a poor prognosis. However, some patients achieved long-term survival after MLN dissection by TT, despite having MLN metastasis. FUTURE There is potential for improving patients’ prognosis by performing thorough MLN dissection by TT for patients with EGJ cancer with EIL [ 20 mm with a likelihood of MLN metastases as well as by adding perioperative therapy to reduce lymphatic tumor spread.6
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