Distribution of lymph node metastases in esophageal adenocarcinoma after neoadjuvant chemoradiation therapy: a prospecti
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Distribution of lymph node metastases in esophageal adenocarcinoma after neoadjuvant chemoradiation therapy: a prospective study Eliza R. C. Hagens1 · Hannah T. Künzli2 · Anne‑Sophie van Rijswijk1 · Sybren L. Meijer3 · R. Clinton D. Mijnals3 · Bas L. A. M. Weusten2 · E. Debby Geijsen4 · Hanneke W. M. van Laarhoven5 · Mark I. van Berge Henegouwen1 · Suzanne S. Gisbertz1 Received: 14 May 2019 / Accepted: 9 October 2019 © The Author(s) 2019
Abstract Background The distribution of lymph node metastases in esophageal adenocarcinoma following neoadjuvant chemoradiation (nCRTx) is unclear, but may have consequences for radiotherapy and surgery. The aim of this study was to define the distribution of lymph node metastases and relation to the radiation field in patients following nCRTx and esophagectomy. Methods Between April 2014 and August 2015 esophageal adenocarcinoma patients undergoing transthoracic esophagectomy with 2-field lymphadenectomy following nCRTx were included in this prospective observational study. Lymph node stations according to AJCC 7 were separately investigated. The location of lymph node metastases in relation to the radiation field was determined. The primary endpoint was the distribution of lymph node metastases and relation to the radiation field, the secondary endpoints were high-risk stations and risk factors for lymph node metastases and relation to survival. Results Fifty consecutive patients were included. Lymph node metastases were found in 60% of patients and most frequently observed in paraesophageal (28%), left gastric artery (24%), and celiac trunk (18%) stations. Fifty-two percent had lymph node metastases within the radiation field. The incidence of lymph node metastases correlated significantly with ypT-stage (p = 0.002), cT-stage (p = 0.005), lymph angioinvasion (p = 0.004), and Mandard (p = 0.002). The number of lymph node metastases was associated with survival in univariable analysis (HR 1.12, 95% CI 1.068–1.173, p 9 mm short axis or a node 5–9 mm short axis that is round, inhomogeneous, and has an irregular border (2 out of 3). If high paratracheal lymph node involvement (station 2) that would change the surgical plan from Ivor Lewis to McKeown was suspected on PET–CT, EBUS was performed to determine if they were positive. This lymph node station would be included in the radiation field and surgical resection if the lymph node was positive. Treatment consisted of nCRTx (i.e. weekly carboplatin AUC 2 and paclitaxel 50 mg/m2 for 5 weeks combined with daily radiotherapy consisting of 23 fractions of 1.8 Gray: total of 41.4 Gray) followed by minimally invasive surgery [20, 21]. The clinical target volume was defined prior to neoadjuvant treatment as the gross tumor volume plus a margin for subclinical disease. The standard clinical target volume consisted of the gross tumor volume plus a margin of 3 cm in cranio-caudal direction. All clinical suspected lymph nodes were included in the radiation field. The details of surgical treatment have b
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