Is there a role for radical esophagectomy

The aim of primary surgery in the treatment of carcinoma of the esophagus a nd gastroesophageal junction (GEJ) is definite cure. To obtain this goal Ro resection, i.e. complete macroscopic and microscopic removal is of paramou nt importance. However, one of the most controversial questions remains the extent of lymph node dissection, in particular the value of cervical lymph node dissection (the so called thud field). Three arguments are believed t o favour more extended lymphadenectomy: optimal staging, prolonged tumour c ontrol, improved cure rate. (a) Optimal staging: available data indicate th at unforeseen lymph node involvement in the neck is encountered in approxim ately 30% of the patients after 3-field lymphadenectomy. Even in tumours of the GEJ up to 20% of the patients in the T3N+ setting have unforeseen posi tive nodes in the neck. (b) Prolonged tumour control: radical esophagectomy and extensive lymphadenectomy is decreasing locoregional recurrence substa ntially, below 10%, in several published reports. More over extended lympha denectomy seems to defer onset of locoregional recurrence and generalised m etastasis for up to 3 years or more. (c) Improved cure rate: despite a lack of prospective randomised study many studies indicate a distinct survival benefit after radical esophagectomy and extensive lymphadenectomy. From the available data it becomes clear that radical surgery and extensive lymphad enectomy offers the best chances for prolonged survival or cure. This can b e done without increasing hospital mortality and morbidity. Survival figure s obtained by this technique are a gold standard to which survival obtained by other techniques (e.g. multimodality treatment forms, VATS resections) have to be compared. (C) 1999 Elsevier Science B.V. All rights reserved.