Minimally Invasive Resection for Oncologically Borderline Distant Lymph Node Metastasis in Esophageal Cancer: Is This Extended or Less-Invasive Surgery?

Excerpt

Neoadjuvant treatment (chemoradiotherapy or chemotherapy) followed by esophagectomy delivered using the Chemoradiotherapy for Esophageal Cancer followed by Surgery Study (CROSS), fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT), or docetaxel, cisplatin and 5-fluorouracil (DCF) regimen has become the standard therapy for resectable, locally advanced esophageal cancer (mainly stage II–III) and provides favorable survival outcomes.^1‐3 On the other hand, with stage IV disease, the cancer is no longer localized and requires systemic nonsurgical treatments: chemotherapy and chemoimmunotherapy with or without radiation therapy. A subsequent esophagectomy is only performed if a small amount of cancer remains at the end of the nonsurgical treatment. Esophagectomy is generally not indicated in cases with distant organ metastasis, but the situation is slightly different in cases with distant lymph node (LN) metastasis. So, what is the difference between regional LN and distant LN metastasis? Notably, whether a LN is defined as regional or distant will depend on one’s country or region. For example, a metastatic supraclavicular LN was recently defined as distant metastasis in the Japanese Classification of Esophageal Cancer, which is consistent with the American Joint Committee on Cancer (AJCC) staging system; nonetheless, it is still targeted for dissection (three-field LN dissection) in Japan, although this is not so in the USA or Europe. On the other hand, pretracheal LNs [paratracheal LNs (4R) in the AJCC classification] and LNs on the dorsal side of the aorta are defined as distant LNs in the Japanese classification but as regional mediastinal LNs in the AJCC classification. Despite these differences, one thing that can be said with certainty is that, in this era of preoperative adjuvant treatment, distant LN metastasis can be eliminated or downstaged before surgery, and an increasing number of cases are eligible for R0 surgery. It can therefore be said that preoperative treatment reduces the weight of distant LN metastasis. …