Impact of Lymphadenectomy on Survival After Unimodality Transthoracic Esophagectomy for Adenocarcinoma of Esophagus

  • A. W. PhillipsEmail author
  • K. Hardy
  • M. Navidi
  • S. K. Kamarajah
  • A. Madhavan
  • A. Immanuel
  • S. M. Griffin
Thoracic Oncology



Debate remains regarding the extent of lymphadenectomy required with esophagectomy. In patients who receive neoadjuvant treatment, this may address lymph node metastases. However, patients with early disease and those with comorbidities may not receive neoadjuvant treatment. The aim of this study is to determine the impact of lymph node yield and location on prognosis in patients undergoing esophagectomy without neoadjuvant treatment.

Patients and Methods

Data from consecutive patients with potentially curable adenocarcinoma of the esophagus or gastroesophageal junction were reviewed. Patients were treated with transthoracic esophagectomy and two-field lymphadenectomy. Outcomes according to lymph node yield were determined. The prognosis of carrying out less radical lymphadenectomy was calculated according to three groups: exclusion of proximal thoracic nodes (group 1), minimal abdominal lymphadenectomy (group 2), and minimal abdominal and thoracic lymphadenectomy (group 3).


357 patients were included. Median survival was 78 months [confidence interval (CI) 53–103 months]. Absolute lymph node retrieval was not related to survival (p = 0.920). An estimated additional 4 (2–6) cancer-related deaths was projected if group 1 nodes were omitted, 15 (11–19) additional deaths if group 2 nodes were omitted, and 4 (2–6) deaths if group 3 nodes were omitted. Minimal lymphadenectomy (groups 1, 2, and 3) was projected to lead to 19 (15–23) additional cancer-related deaths.


Extensive lymphadenectomy allows accurate staging. In patients who do not receive neoadjuvant treatment, it may confer a survival benefit. The number of lymph nodes retrieved may not be a good surrogate for extent of lymphadenectomy, and correlation with location is required.



The authors thank Helen Jaretkze NOGU data manager for assistance in the manuscript preparation.


The authors declare that no support or grants were received for this work and no conflict of interest.


  1. 1.
    Cunningham D, Allum WH, Stenning SP, Thompson JN, Van de Velde CJH, Nicolson M, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med. 2006;355(1):11–20. Scholar
  2. 2.
    Allum WH, Stenning SP, Bancewicz J, Clark PI, Langley RE. Long-term results of a randomized trial of surgery with or without preoperative chemotherapy in esophageal cancer. J Clin Oncol. 2009;27(30):5062–7.CrossRefGoogle Scholar
  3. 3.
    Rizk NP, Ishwaran H, Rice TW, Chen L-Q, Schipper PH, Kesler KA, et al. Optimum lymphadenectomy for esophageal cancer. Ann Surg. 2010;251(1):46–50.CrossRefGoogle Scholar
  4. 4.
    Visser E, Markar SR, Ruurda JP, Hanna GB, van Hillegersberg R. Prognostic value of lymph node yield on overall survival in esophageal cancer patients. Ann Surg. 2018;1.Google Scholar
  5. 5.
    Boshier PR, Anderson O, Hanna GB. Transthoracic versus transhiatal esophagectomy for the treatment of esophagogastric cancer: a meta-analysis. Ann Surg. 2011;254(6):894–906.CrossRefGoogle Scholar
  6. 6.
    Kutup A, Nentwich MF, Bollschweiler E, Bogoevski D, Izbicki JR, Hölscher AH. What should be the gold standard for the surgical component in the treatment of locally advanced esophageal cancer: transthoracic versus transhiatal esophagectomy. Ann Surg. 2014;260(6):1016–22.CrossRefGoogle Scholar
  7. 7.
    Davies AR, Sandhu H, Pillai A, Sinha P, Mattsson F, Forshaw MJ, et al. Surgical resection strategy and the influence of radicality on outcomes in oesophageal cancer. Br J Surg. 2014;101(5):511–7.CrossRefGoogle Scholar
  8. 8.
    Duan X-F, Tang P, Shang X-B, Jiang H-J, Yu Z-T. The prevalence of lymph node metastasis for pathological T1 esophageal cancer: a retrospective study of 143 cases. Surg Oncol. 2018;27(1):1–6.CrossRefGoogle Scholar
  9. 9.
    Newton AD, Predina JD, Xia L, Roses RE, Karakousis GC, Dempsey DT, et al. Surgical management of early-stage esophageal adenocarcinoma based on lymph node metastasis risk. Ann Surg Oncol. 2018;25(1):318–25.CrossRefGoogle Scholar
  10. 10.
    Allum WH, Blazeby JM, Griffin SM, Cunningham D, Jankowski JA, Wong R. Guidelines for the management of oesophageal and gastric cancer. Gut. 2011;60(11):1449–72.CrossRefGoogle Scholar
  11. 11.
    Darling G. The role of lymphadenectomy in esophageal cancer. J Surg Oncol. 2009;99(4):189–93.CrossRefGoogle Scholar
  12. 12.
    Hosch S, Kraus J, Scheunemann P, Izbicki JR, Schneider C, Schumacher U, et al. Malignant potential and cytogenetic characteristics of occult disseminated tumor cells in esophageal cancer. Cancer Res. 2000;60(24):6836–40.PubMedGoogle Scholar
  13. 13.
    Izbicki JR, Hosch SB, Pichlmeier U, Rehders A, Busch C, Niendorf A, et al. Prognostic value of immunohistochemically identifiable tumor cells in lymph nodes of patients with completely resected esophageal cancer. N Engl J Med. 1997;337(17):1188–94.CrossRefGoogle Scholar
  14. 14.
    Glickman JN, Torres C, Wang HH, Turner JR, Shahsafaei A, Richards WG, et al. The prognostic significance of lymph node micrometastasis in patients with esophageal carcinoma. Cancer. 1999;85(4):769–78.CrossRefGoogle Scholar
  15. 15.
    Vazquez-Sequeiros E, Wang L, Burgart L, Harmsen W, Zinsmeister A, Allen M, et al. Occult lymph node metastases as a predictor of tumor relapse in patients with node-negative esophageal carcinoma. Gastroenterology. 2002;122(7):1815–21.CrossRefGoogle Scholar
  16. 16.
    Talsma AK, Xinxue CJO, Pieter L, Wijnhoven BPL, Ong C-AJ, Liu X, et al. Location of lymph node involvement in patients with esophageal adenocarcinoma predicts survival. World J Surg. 2014;38(1):106–13.Google Scholar
  17. 17.
    Phillips AW, Lagarde SM, Navidi M, Disep B, Griffin SM. Impact of extent of lymphadenectomy on survival, post neoadjuvant chemotherapy and transthoracic esophagectomy. Ann Surg. 2017;265(4):750–6.CrossRefGoogle Scholar
  18. 18.
    McK Manson J, Beasley WD. A personal perspective on controversies in the surgical management of oesophageal cancer. Ann R Coll Surg Engl. 2014;96(8):575–8.CrossRefGoogle Scholar
  19. 19.
    Sobin LH. TNM classification of malignant tumours. 7th ed. New York: Wiley; 2009.Google Scholar
  20. 20.
    Phillips AW, Dent B, Navidi M, Immanuel A, Griffin SM. Trainee involvement in Ivor Lewis esophagectomy does not negatively impact outcomes. Ann Surg. 2018;267(1):94–8.CrossRefGoogle Scholar
  21. 21.
    Lagarde SM, Phillips AW, Navidi M, Disep B, Griffin SM. Clinical outcomes and benefits for staging of surgical lymph node mapping after esophagectomy. Dis Esophagus. 2017;30(12):1–7.CrossRefGoogle Scholar
  22. 22.
    Mapstone N. Dataset for the histopahtological reporting of oesophageal carcinoma. 2nd ed. 2007.Google Scholar
  23. 23.
    Schaaf MVD, Johar A, Wijnhoven B, Lagergren P, Lagergren J, van der Schaaf M, et al. Extent of lymph node removal during esophageal cancer surgery and survival. JNCI J Natl Cancer Inst. 2015; 107(5):djv043–djv043.Google Scholar
  24. 24.
    Lagergren J, Mattsson F, Zylstra J, Chang F, Gossage J, Mason R, et al. Extent of lymphadenectomy and prognosis after esophageal cancer surgery. JAMA Surg. 2015;1–8.Google Scholar
  25. 25.
    Veloski J, Boex JR, Grasberger MJ, Evans A, Wolfson DB. Systematic review of the literature on assessment, feedback and physicians’ clinical performance: BEME Guide No. 7. Med Teach. 2006;28(2):117–28.Google Scholar
  26. 26.
    Omloo JMT, Lagarde SM, Hulscher JBF, Reitsma JB, Fockens P, van Dekken H, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the mid/distal esophagus. Ann Surg. 2007;246(6):992–1001.CrossRefGoogle Scholar
  27. 27.
    Rice TW, Gress DM, Patil DT, Hofstetter WL, Kelsen DP, Blackstone EH. Cancer of the esophagus and esophagogastric junction-Major changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA Cancer J Clin. 2017;67(4): 304–17. Scholar
  28. 28.
    Hagens ERC, van Berge Henegouwen MI, van Sandick JW, Cuesta MA, van der Peet DL, Heisterkamp J, et al. Distribution of lymph node metastases in esophageal carcinoma [TIGER study]: study protocol of a multinational observational study. BMC Cancer. 2019;19(1):662.CrossRefGoogle Scholar
  29. 29.
    Sinclair RCF, Phillips AW, Navidi M, Griffin SM, Snowden CP. Pre-operative variables including fitness associated with complications after oesophagectomy. Anaesthesia. 2017;72(12):1501–7.CrossRefGoogle Scholar
  30. 30.
    Low DE, Kuppusamy MK, Alderson D, Cecconello I, Chang AC, Darling G, et al. Benchmarking complications associated with esophagectomy. Ann Surg. 2019;269(2):291–8.CrossRefGoogle Scholar
  31. 31.
    Mariette C, Markar SR, Dabakuyo-Yonli TS, Meunier B, Pezet D, Collet D, et al. Hybrid minimally invasive esophagectomy for esophageal cancer. N Engl J Med. 2019;380(2):152–62.CrossRefGoogle Scholar
  32. 32.
    Navidi M, Phillips AW. Hybrid minimally invasive esophagectomy for esophageal cancer. N Engl J Med. 2019;380(17):e28.CrossRefGoogle Scholar
  33. 33.
    Tapias LF, Mathisen DJ, Wright CD, Wain JC, Gaissert HA, Muniappan A, et al. Outcomes with open and minimally invasive ivor lewis esophagectomy after neoadjuvant therapy. Ann Thorac Surg. 2016;101(3):1097–103.CrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  1. 1.Northern Oesophago-Gastric Cancer UnitRoyal Victoria InfirmaryNewcastle upon TyneUK
  2. 2.School of Medical EducationNewcastle UniversityNewcastle upon TyneUK
  3. 3.Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneUK

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