Extent of lymphadenectomy in esophageal cancer: how many lymph nodes is enough?

If nodal clearance is so important, should a more aggressive operation or adding a cervical field become standard for locally advanced esophageal cancer? Is the survival advantage of more radical operations a direct benefit or the effect of stage migration? In a prospective randomized trial comparing transhiatal (THE) versus transthoracic en bloc (TTE) esophagectomy, Hulscher and colleagues noted a much higher mean number of dissected LN (31 versus 16) and reported a trend towards improved survival, although it did not reach statistical significance. 7 Several surgical series have reported even higher number of dissected LN with improvement in survival even in patients with multiple LN metastases, but an increase in morbidity and possibly in mortality are frequently unavoidable in more radical operations. 8 Whether a more aggressive en bloc or routine three-field lymphadenectomy is a better esophageal cancer operation, or whether the number of dissected lymph nodes is the factor that impacts survival regardless of the technique, will require further investigation.

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