Extended Lymphadenectomy in Esophageal Cancer is Debatable
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Extended Lymphadenectomy in Esophageal Cancer is Debatable Fernando A. M. Herbella • Rafael M. Laurino Neto Marco E. Allaix • Marco G. Patti
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Published online: 4 April 2013 Ó Socie´te´ Internationale de Chirurgie 2013
Abstract Surgery is an essential part of the treatment of patients with esophageal carcinoma. However, there is no consensus on whether the surgical technique can be improved to promote better survival outcome. Specifically, the real value of the addition of a radical lymphadenectomy to the esophageal resection is still elusive and controversial. This paper focuses on the debate of esophagectomy and lymphadenectomy for the treatment of esophageal cancer.
Introduction Esophageal carcinoma (EC) is a devastating disease. The global incidence of EC has regional discrepancies (Fig. 1) [1]; however, the World Health Organization listed EC as the eighth most common cancer worldwide in 2008 with 481,000 new cases (3.8 % of the total), and the sixth most common cause of death from cancer with 406,000 deaths (5.4 % of the total), leading to a mortality rate of 84 %. The United States National Cancer Institute estimates an incidence of 17,460 new cases of EC in US in 2012 with 15,070 deaths expected, a mortality rate of 86 %. Surgery is considered an essential part of the treatment of patients with EC [2] as it has been shown that the nonsurgical approach to EC is associated with poor
F. A. M. Herbella (&) R. M. Laurino Neto Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil e-mail: [email protected] M. E. Allaix M. G. Patti Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
survival outcome [3]. The improvement in survival was initially achieved at the cost of very high morbidity and mortality. For instance, in 1980, Earlam and Cunha-Melo [4] reviewed the literature and reported a 29 % mortality rate for esophagectomy. Some oncologists still quote these numbers as a justification for a nonsurgical approach to EC. However, recent studies have shown that particularly in high-volume centers the mortality rate is about tenfold lower, probably as a result of improvement in anesthesia, analgesia, intensive care, and surgical technique. Nowadays, esophageal resection, with or without chemotherapy or radiotherapy, still was shown to have a better survival rate than the nonsurgical approach [5]. Although some reports have a mortality rate of less than 2 % [6, 7], still a rate of up to 15 % of deaths linked to the surgical procedure is commonly reported in multicenter studies [8, 9]. Unfortunately, the 5-year survival rate has not passed the 40 % level [10]. It is unclear if surgery has reached its limit. Some authors believe that efforts should be focused on perioperative care based on standard protocols [11, 12], while others believe that the surgical procedure still can be improved. This generates controversies in regard to operative technique, such as what is the ideal approach, i.e., open versus minimally invasive
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