The Potential of Lymph Node Yield as a Quality Indicator of Esophagectomy for Esophageal Cancer
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EDITORIAL – GASTROINTESTINAL ONCOLOGY
The Potential of Lymph Node Yield as a Quality Indicator of Esophagectomy for Esophageal Cancer Satoru Matsuda, MD, PhD, and Yuko Kitagawa, MD, PhD, FACS Department of Surgery, Keio University School of Medicine, Tokyo, Japan
Because of the abundant lymphatic routes and anatomic structures connecting the throat with the stomach, esophageal cancer is considered to be a dismal disease likely to involve extensive lymph node (LN) metastasis even in the early stage.1 To prevent the spread of cancer cells by the lymphatic route, surgical resection with extended LN dissection has been the standard procedure.2 Because the extent of LN metastasis may differ depending on the location of the primary tumor and tumor histology, identifying the appropriate field of LN dissection is critical to patient cure. One of the quality indicators suggesting successful esophagectomy with relevant LN dissection is the number of LNs retrieved.3,4 To evaluate the utility of this indicator, a study assessed the prognostic impact from the number of LNs harvested. The findings showed a positive correlation between the number of LNs harvested and the outcome of the esophagectomy.5 Moreover, the number of LNs retrieved is associated with several patient and disease characteristics, including preoperative weight loss, low Charlson comorbidity score, and higher clinical N stage. In addition, stage migration, in which a lower number of LNs examined underestimates the pathologic stage, could exist. Therefore, a larger number of LNs dissected might not simply reflect the extent of lymphadenectomy. For an accurate evaluation of the correlation between LN yield and prognosis, the background data for each patient should be precisely matched to minimize confounding.
Ó Society of Surgical Oncology 2020 First Received: 25 August 2020 Accepted: 3 September 2020 Y. Kitagawa, MD, PhD, FACS e-mail: [email protected]
In the current issue of Annals of Surgical Oncology, we read with great interest how van der Werf et al.6 successfully showed that the number of LNs harvested was associated with more accurate staging but did not have an impact on patient survival. The authors reviewed national data using the Dutch Upper Gastrointestinal Cancer Audit combined with the National Healthcare Insurance Database and retrieved data for esophageal cancer patients who underwent esophagectomy after neoadjuvant chemoradiotherapy (NACRT). In their comprehensive analysis with propensity-score matching, esophageal cancer patients with more than 15 retrieved LNs exhibited a higher proportion of pathology-confirmed positive LN metastasis but showed no difference in survival, indicating that the pathologic stage was appropriately assigned in the high LN-yield group. As noted by the authors, their result was inconsistent with previous findings of the relation between an increased number of LNs retrieved and a better survival outcome. They speculated that this discrepancy might reflect the fact that the current study was carried out after Dut
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