Three-field lymphadenectomy and pattern of lymph node spread in T3 adenocarcinoma of the distal esophagus and the gastro-esophageal junction

Objective. Lymph nude metastasis in carcinoma of the esophagus and the gast ro-esophageal junction is often underestimated by clinical staging. It is t he aim of this study to provide support to the fact that three-field lympha denectomy leads to a better pathological staging also in adenocarcinoma. Me thods: The pattern of lymph node metastasis in adenocarcinoma of the gastro -esophageal junction (GEJ) and the distal esophagus was charted in a prospe ctive way by using a database. An analysis was performed with regard to lym phatic spread in T-3, N+ adenocarcinomas of the distal esophagus and the GE J junction, which were treated with a radical resection including a three-f ield lymphadenectomy. Out of 324 patients with adenocarcinoma of the esopha gus and GEJ, we selected a group of 37 patients with an adenocarcinoma T-3, N+ of the distal (n = 17) or GEJ junction (n = 20), treated with a radical resection and three-field lymphadenectomy (> 25 lymph nodes resected). Res ults: In total, 2240 lymph nodes were removed, with a mean of 59.5 per pati ent. In the GEJ group the ratio of positive nodes was 15.9, in the distal 1 /3 group this ratio was 12.7%. Abdominal lymph nodes were positive in all G EJ tumors and in 70% of the distal third carcinomas. Thoracic lymph nodes w ere positive in 40% of GEJ tumors, and 70.6% of the distal group. Cervical lymph nodes were positive in 20% of the GEJ tumors and in 35.3% of the dist al tumors. In six patients only right-sided cervical nodes were affected. T hree patients in the GEJ group had positive lymph nodes in the neck without any involvement of thoracic lymph nodes. Conclusions: (1) Three-field lymp hadenectomy improves accuracy of staging. (2) Cervical nodes are frequently involved. (3) Especially in tumors of the GEJ there is an important skippi ng phenomenon. i.e. positive lymph nodes in the neck in the absence of invo lvement of thoracic nodes. (4) Clinical staging remains deficient in regard to lymph node metastasis, especially cervical nodes. (5) The frequent unfo reseen involvement of cervical lymph nodes in adenocarcinoma of the distal esophagus and GEJ tumors makes the interpretation of results of induction c hemoradiotherapy questionable. (6) For the same reason, cervical lymph node s should be included in the radiation field in case of induction chemoradio therapy. (7) The similar pattern of lymph node involvement suggests similar oncological behavior of adenocarcinoma of the distal esophagus and the GEJ , questioning the actual TNM classification of these tumors as gastric carc inomas. (C) 1999 Elsevier Science B.V. All rights reserved.