New insights in the lymphatic spread of oesophageal cancer and its implications for the extent of surgical resection

In this review new insights in the dissemination pattern of oesophageal tumours and the implications for the (extent of) surgical and endoscopic resection are discussed. Moreover, the sentinel node concept in oesophageal cancer is reconsidered. Three-years survival after a limited resection for cervical-upper thoracic oesophageal cancer was 14-20% after an extended resection.(1,2) No patients with distant metastases were alive after five years.' Therefore, curative surgery for cervical-upper oesophageal cancer with extended lymph node dissection is probably only indicated in patients without distant lymph nodes metastases.(3) Involved coeliac nodes can be found in tumours of the whole oesophagus.(4) Adenocarcinomas of the gastrooesophageal junction do metastasize predominately to the paracardial and lesser curvature regions.(5) No significant difference was found in a randomized trial comparing two-field transthoracic resection with limited transhiatal resection for adenocarcinoma of the gastrooesophageal junction.(6) Subgroup analysis for patients with a distal oesophageal adenocarcinoma revealed a 17% survival benefit after transthoracic resection.(7) In several Japanese studies a better five-year survival is claimed after a three-field lymph node dissection than after a conventional two-field lymphadenectomy.(4,8,9) In a randomized study, however, no statistically significant difference was found in the short- and long-term survival nor in the recurrence rate.(9) If an early lesion is limited to the mucosa, endoscopic mucosal resection (EMR) could be considered because of the low chance of lymph node metastases.(10-12) However, the technique of EMR has not yet been optimized resulting in high numbers of local cancer recurrences and a high need for endoscopic re-resections.(10,13). Only few studies investigated whether the sentinel node concept is applicable to the oesophagus or gastric cardia.(14-17) In one study in patients with oesophageal or cardia cancer, the accuracy was 96% and only two false negative sentinel nodes were identified.(15) The sentinel node concept in oesophageal cancers might change future operative strategies.