Reflections on three field lymphadenectomy in carcinoma of the esophagus and gastroesophageal junction

BACKGROUND/AIMS: One of the most controversial questions in the surgical tr eatment of carcinoma of the esophagus and gastroesophageal junction (GEJ) i s the extent of lymph node dissection, in particular the value of the cervi cal lymph node dissection (the so-called third field). METHODOLOGY: This study reflects a single institution's experience with thi s extensive lymphadenectomy, the technique of which is described in detail. RESULTS: Adding the third field to the lymph node dissection markedly impro ved accuracy of staging. Unforeseen involvement of lymph nodes in the neck was found in 30%. In T3N+ tumors of the GEJ, as much as 16.6% of positive l ymph nodes were detected in the neck. Locoregional recurrence without dista nt metastasis was found in 6 patients (17.8%) out of a group of 37 patients with a minimum follow-up of 5 years. All 6 patients had stage TV disease b ecause of distant lymph node metastasis (M+Ly). In 3 of these patients, loc oregional recurrence occurred only after 3 years or more. In a subsequent s eries of 100 esophagectomies performed between 1992 and July 1993 no differ ence in outcome between radical versus standard resection was noticed for e arly stage I and II. However, there is a tendency towards a better estimate d 5-year survival in favor of radical dissections (21%) versus standard res ection (12%) in stage III and IV. CONCLUSIONS: Extensive three field lymphadenectomy can be safely performed without increasing hospital mortality (0%) and morbidity. Improved accuracy of staging, prolonged disease-free survival and potential increased cure r ate are confirmed by our experience. Survival obtained with this technique has to be compared with survival obtained by other, multimodality treatment forms.