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Ricardo Beyruti

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    WS05 - Staging Workshop Part 2: The Importance of Invasive Nodal Staging in Thoracic Malignancies (ID 106)

    • Event: WCLC 2019
    • Type: Workshop
    • Track: Staging
    • Presentations: 6
    • Now Available
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      WS05.01 - Invasive Pre-Operative Staging of Lung Cancer (Now Available) (ID 3684)

      15:45 - 17:15  |  Presenting Author(s): Sergi Call

      • Abstract
      • Presentation
      • Slides


      Although reliable mediastinal staging is essential for the management of NSCLC, the optimal approach to invasive mediastinal staging remains controversial.

      According on the current guidelines, preoperative invasive mediastinal staging can be omitted if all the following criteria apply: a) primary tumour located in the outer third of the lung; b) largest diameter of the tumour is ≤3 cm; c) absence of intrathoracic lymph node(s) on CT and PET (1,2). The rationale is that, in this situation, the rate of unsuspected pathologic mediastinal nodal disease is < 10% (3,4).

      When tumours are classified as clinical (c) N2-3 on PET-CT, the risk of mediastinal nodal involvement is at least 60% (1). In this situation, it is mandatory to pathologically confirm all abnormalities detected by CT or PET starting with an endosonography method (EBUS-FNA, EUS-FNA or their combination) and to reserve mediastinoscopy to validate their negative results (1,2).

      Regarding those tumours with an intermediate risk of N2-3 disease (and normal mediastinum by CT and PET) the rate of unsuspected N2 disease is: 20%-42%, for tumours classified as cN1, and 6%- 22.2% for tumours classified as cN0 and tumour size greater than 3cm (5-8). For these clinical scenarios, there is a little disagreement between American and European guidelines about the best staging procedure to start with. The American College of Chest Physicians (ACCP) guidelines suggest endosonography methods over surgical procedures (1), and the European Society of Thoracic Surgeons (ESTS) guidelines describe that the choice between mediastinoscopy with biopsies, or with pre-surgical lymphadenectomies or endoscopic staging by EBUS/EUS with FNA depends on local expertise (1,2). Regarding the accuracy of invasive mediastinal staging methods in this type of patients (clinical N0 disease by PET-CT), minimally invasive endoscopic techniques have a poor sensitivity (0.17-0.41) (5,9). On the other hand, due to the fact that performance of mediastinoscopy is investigator dependent, there is an important heterogeneity in the reported sensitivity and negative predictive values : 0.32 to 0.97 and 0.8 to 0.99, respectively (2). Transcervical lymphadenectomies (video-assisted mediastinoscopic lymphadenectomy[VAMLA] and transcervical extended mediastinal lymphadenectomy[TEMLA]) are the only pre-surgical staging procedures with the highest sensitivity and negative predictive value reported to date for those patients with normal mediastinum by PET and CT: 0.88-0.96 and 0.94-0.99, respectively (8-10). Focusing oncN1 tumors, endosonography methods have a reported sensitivity ranging from 0.38 to 0.43. (5,6). This sensitivity increased to 0.73 by adding a confirmatory mediastinoscopy to validate negative endosonographies (6). Based on the results from the first prospective multicentre study (ASTER III) to evaluate the performance of surgical mediastinal staging (by mediastinoscopy or by VAMLA) in patients with cN1, the superiority of surgical method was confirmed obtaining a global sensitivity of 0.73 and a negative predictive value of 0.92 (7). Regarding those tumours with high SUVmax, cN0 but size greater than 3cm and specially in adenocarcinomas the rate of unsuspected N2 is: 6%-14.8% (3,4). A recent prospective study to validate the feasibility and accuracy of VAMLA reported a rate of 22.2% of unsuspected N2 disease for cN0 tumour >3cm (19% N2 tumours and 3,2% N3 tumours) (8). Therefore, based on this results, it is recommendable to validate negative results of endosonographies with a surgical procedure in the same line of those patients with tumours classified as cN1.


      Currently, surgical methods are mainly indicated to validate negative results of minimally invasive endoscopic techniques for those tumours with high suspicion of mediastinal involvement by PET-CT. Based on the latest evidence, mediastinoscopy and, especially, transcervical lymphadenectomies are the most reliable staging methods for the subgroup of patients with intermediate risk of N2 disease and normal mediastinum by PET and CT. Consequently, future staging algorithms should recommend surgical methods as the preferred technique for this subset of patients.


      1. De Leyn P, Dooms C, Kuzdzal J, et al. Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer. Eur J Cardiothorac Surg 2014;45:787-98

      2. Silvestri GA, Gonzalez AV, Jantz MA, et al. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143: e211S-e250S

      3. Wang J, Welch K, Wang L, et al. Negative predictive value of positron emission tomography and computed tomography for stage T1-2N0 non-small-cell lung cancer: a meta-analysis. Clin Lung Cancer 2012;13:81-9.

      4. Gómez-Caro A, Boada M, Cabañas M, et al. False-negative rate after positron emission tomography/ computer tomography scan for mediastinal staging in cI stage non-small-cell lung cancer. Eur J Cardiothorac Surg 2012;42:93-100

      5. Yasufuku K, Nakajima T, Waddell T, et al. Endobronchial ultrasound-guided transbronchial needle aspiration for differentiating N0 versus N1 lung cancer. Ann Thorac Surg 2013;96:1756-1760.

      6. Dooms C, Tournoy KG, Schuurbiers O, et al. Endosonography for mediastinal nodal staging of clinical N1 non-small cell lung cancer: a prospective multicenter study. Chest 2015;147:209-2015.

      7. Decaluwé H, Dooms C, D'Journo XB, et al. Mediastinal staging by videomediastinoscopy in clinical N1 non-small cell lung cancer: a prospective multicentre study. Eur Respir J 2017;50: 1701493

      8. Call S, Obiols C, Rami-Porta R, et al. Video-assisted mediastinoscopic lymphadenectomy for staging non-small cell lung cancer. Ann Thorac Surg 2016;101:1326-33

      9. Vial M, O’Connell O, Grosu H, et al. Diagnostic performance of endobronchial ultrasound-guided mediastinal lymph node sampling in early stage non-small cell lung cancer: A prospective study. Respirology 2018;23:76-81.

      10. Zielinski M, Hauer L, Hauer J, et al. Transcervical extended mediastinal lymphadenectomy (TEMLA) for staging of non-small-cell lung cancer (NSCLC). Pneumonol Alergol Pol 2011;79:196–206.

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      WS05.02 - "Loge De Baréty": What and Where It Is and Its Relation with the IASLC Lymph Node Map (Now Available) (ID 3685)

      15:45 - 17:15  |  Presenting Author(s): Francoise Le Pimpec-Barthes

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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      WS05.03 - How to Perform a Proper Systematic Nodal Dissection in Lung Cancer Surgery (Now Available) (ID 3686)

      15:45 - 17:15  |  Presenting Author(s): Kyohei Masai  |  Author(s): Kaoru Kaseda, Keisuke Asakura, Tomoyuki Hishida, Hisao Asamura

      • Abstract
      • Presentation
      • Slides


      In 1960, Cahan first reported lobectomy with regional lymph node dissection, which was called “radical lobectomy.”1 Since then, this procedure has been widely accepted, and systematic nodal dissection (SND) is an internationally accepted standard procedure for lymph node dissection in cases of non-small cell lung cancer (NSCLC). The purpose of SND is aimed at removal of all mediastinal lymph node stations regardless of the anatomical location of the primary tumor in the lobe. The significance of SND can be discussed from the clinical aspects of accurate staging and survival benefit. Metastatic lymph nodes obtained via SND can undergo careful and accurate accurate histopathological evaluation, which offers several clinical advantages. However, the therapeutic effect of SND remains unclear.2-5

      Technically, SND involves complete excision of all tissues in a particular anatomical compartment along with a few components of surrounding anatomical structures. An ideal technique involves en bloc removal of all tissue that may contain cancer cells, including lymph nodes and surrounding fatty tissue within pre-defined anatomical landmarks. All of lobectomies for NSCLC are performed via posterolateral incision using minimally invasive open surgery (MIOS) approach in our institution. Common to both sides, the fourth or fifth intercostal space provides better access in SND. During the SND, special care is warranted to prevent interruption of the lymphatic vessels and/or injury to the lymph nodes themselves. Additionally, connective tissue ligation is necessary in a few cases to prevent postoperative chylothorax. Identification of the bilateral recurrent nerves is important because recurrent nerve paralysis can cause serious postoperative complications. Based on AOSOG Z0030 trial, complications of SND include postoperative chylothorax (1.7%), intraoperative bleeding (1.1%), and recurrent laryngeal nerve injury (0.9%).5

      Although SND is a standard procedure of lymph node dissection for NSCLC, previous studies have analyzed in detail the lymphatic pathway and the pattern of lymph node involvement based on the primary location by lobe. Asamura et al. 6 reported that right upper lobe tumors and left upper segment tumors tend to metastasize to the superior mediastinum and that these lesions rarely metastasize to the subcarinal nodes without concomitant metastasis to the hilar or superior mediastinal nodes.6 The lobe-specific patterns of nodal metastases are being recognized owing to increasing analyses of the lymph node metastatic pathway.6-9 Based on these results, lobe-specific lymph node dissection is being increasingly performed under certain conditions, for example, based on tumor location, tumor size, cell type, and the percentage of the area of ground glass opacity visualized in the tumor on computed tomography.


      1. Cahan WG. Radical lobectomy. J Thorac Cardiovasc Surg; 1960;39:555-572.
      2. Izbicki JR, Passlick B, Pantel K, et al. Effectiveness of radical systematic mediastinal lymphadenectomy in patients with resectable non small cell lung cancer. Ann Surg 1998;227:138-144.
      3. Sugi K, Nawata K, Fujita N, et al. Systematic lymph node dissection for clinically diagnosed peripheral non-small-cell lung cancer less than 2 cm in diameter. World J Surg 1998;22:290-294.
      4. Wu Y, Huang ZF, Wang SY, et al. A randomized trial of systematic nodal dissection in resectable non-small cell lung cancer. Lung Cancer 2002;36:1- 6.
      5. Wright G, Manser RL, Byrnes G, et al. Surgery for non-small cell lung cancer: systematic review and meta-analysis of randomised controlled trials. Thorax 2006;61:597-603.
      6. Asamura H, Nakayama H, Kondo H, Tsuchiya R, Naruke T. Lobe-specific extent of systematic lymph node dissection for non-small cell lung carcinomas based on a retrospective study of metastasis and prognosis. J Thorac Cardiovasc Surg 1999; 117:1102-1111
      7. Asamura H, Nakayama H, Kondo H, Tsuchiya R, Naruke T. Lymph node involvement, recurrence, and prognosis in resected small, peripheral non-small cell carcinoma of the lung. Are these carcinomas candidates for video-assisted lobectomy? J Thorac Cardiovasc Surg 1996;111:1125-1134
      8. Okada M, Tsubota N, Yoshimura M, et al. Prognosis of completely resected pN2 non-small cell carcinomas: what is the significant node that affects survival? J Thorac Cardiovasc Surg 1999;118:270-275
      9. Watanabe S, Suzuki K, Asamura H. Superior and basal segment lung cancers in the lower lobe have different lymph node metastatic pathways and prognosis. Ann Thorac Surg 2008;85:1026-1031.

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      WS05.04 - Particularities of Lymphadenectomy in Malignant Pleural Mesothelioma (Now Available) (ID 3687)

      15:45 - 17:15  |  Presenting Author(s): Andrea Bille

      • Abstract
      • Presentation
      • Slides


      Malignant Pleural Mesothelioma (MPM) is an aggressive disease with a poor prognosis. Patients treated with multimodality approach have a survival of 20 to 30 months. Survival is worse in patients with nodal disease1. Lymph node involvement is reported in 35 to 50% of patients undergone surgery. The lymph node staging system and the nodal categories (N0–N3) in the mesothelioma TNM staging are based on the lung cancer TNM. There are significant anatomic differences between the lymphatic drainage pathways of the pleura and the lung parenchyma2. The parietal and visceral pleura have two distinct and separate lymphatic drainage probably. The MPM arises from the parietal pleura and the intrapulmonary lymph node may not be the first lymph nodes to be involved, but they may be involved in a later phase. The lymph drainage of the parietal pleura flows initially through intercostal lymphatic channels, anteriorly to the internal thoracic artery nodes or posteriorly to the internal intercostal lymph nodes (Figure 1). Drainage can also be directly into axillary or cervical lymph nodes. Diaphragmatic lymphatic drainage can flow into mediastinal, internal thoracic, or abdominal nodes3.

      The MPM may involve also the endothoracic fascia, the chest wall, the mediastinal adipose tissue, the pericardium and the diaphragm, making the lymphatic drainage more complex. The intercostal space lymph nodes, the paraspinal lymph nodes, the peri diaphragmatic lymph nodes and the internal mammary chain lymph nodes may be the first lymphatic stations to be involved rather than the intrapulmonary lymph nodes.

      It was reported that extrapleural and the mediastinal nodes (N2) may in fact be the initial site of nodal metastases in patients with mesothelioma, with N1 nodes becoming secondarily involved only when invasion of lung parenchyma occur4.

      Data from several single-institutional retrospective series have yielded conflicting evidence as to whether there is indeed a prognostic difference between patients with pathologic N1 (pN1) and pN2 pleural mesothelioma. Those data are based on the lymph node mapped derived from lung cancer staging system. The IALSC TNM collected data from 29 institution and specifically analysed the impact of pathological nodal status on survival5,6. 851 cases were eligible for the pathological N status analysis. According to the analysis for the revision of the N descriptor the survival of pN1 and pN2 was 16.9 and 17.4 months (p=0.28)5. Interestingly 54% had skip metastases based on the lung cancer staging map. Based on this evidence in the 8th TNN edition N1 and N2 were grouped together3 and N3 disease was re classified as N2 disease.

      Like for other tumours, such as breast or melanoma, few papers tried to identified a sentinel lymph node in MPM with no success7. In the paper of Edwards et al8 there is no mention of the intercostal lymph nodes sampling, reflecting how limited the data on lymph node mapping are and how variable is the sampling technique between surgeons.

      During the operation an extensive nodal sampling should be performed. The intercostal lymph node at different levels, the mediastinal and intrapulmonary stations, the peri diaphragmatic and the internal mammary lymph nodes should be sampled. Specifically, the peri diaphragmatic lymph node should be categorized in above and below the diaphragm if the diaphragm is removed. All these lymph node stations should be sampled to collect more data on the lymph node drainage and spread of the disease according to the parietal and visceral pleura involvement.

      In conclusion, there is variability in the lymphatic drainage in mesothelioma. The lymph node map we used for mesothelioma is inadequate and a different lymph node map specific for mesothelioma should be created based on the different lymphatic drainage of the parietal and visceral pleura compared to the lung. There are no guidelines in how to perform lymph node sampling in mesothelioma. A routine lymphadenectomy should be performed at the time of surgery considering extrapleural, mediastinal and intrapulmonary lymph node stations according to the different lymphatic drainage of the parietal and visceral pleura.


      Flores RM, Routledge T, Seshan VE, et al. The impact of lymph node station on survival in 348 patients with surgically resected malignant pleural mesothelioma: implications for revision of the American Joint Committee on Cancer staging system. J Thorac Cardiovasc Surg. 2008 Sep; 136:605–610

      Okiemy G, Foucault C, Avisse C, et al. Lymphatic drainage of the diaphragmatic pleura to the peritracheobronchial lymph nodes. Surg Radiol Anat. 2003; 25:32–35.

      John G. Edwards, PhD, FRCS,a D. J. Stewart, FRCS,a Antonio Martin-Ucar, FRCS,a Salli Muller, Cathy Richards, FRCPath,b and David A. Waller, The pattern of lymph node involvement influences outcome after extrapleural pneumonectomy for malignant mesothelioma. J Thorac Cardiovasc Surg 2006;131:981-7

      Abdel Rahman AR, Gaafar RM, Baki HA, et al. Prevalence and pattern of lymph node metastasis in malignant pleural mesothelioma. Ann Thorac Surg. 2008;86: 391–395.

      Rice D, Chansky K, Nowak A, Pass H, Kindler H, Shemanski L, Opitz I, Call S, Hasegawa S, Kernstine K, Atinkaya C, Rea F, Nafteux P, Rusch VW; The IASLC Mesothelioma Staging Project: Proposals for Revisions of the N Descriptors in the Forthcoming Eighth Edition of the TNM Classification for Pleural Mesothelioma. Mesothelioma Domain of the IASLC Staging and Prognostic Factors Committee, advisory boards and participating institutions.J Thorac Oncol. 2016 Dec;11(12):2100-2111

      Rusch VW, Giroux D, Kennedy C, et al. Initial analysis of the International Association for the Study of Lung Cancer mesothelioma database. J Thorac Oncol. 2012; 7:1631–1639

      Cherie P. Parungo, Yolonda L. Colson, MD, PhD, Sang-Wook Kim, PhD, Sungjee Kim,
      PhD, Lawrence H. Cohn, MD, Moungi G. Bawendi, PhD, and John V. Frangioni, MD, PhD. Sentinel Lymph Node Mapping of the Pleural Space. Chest. 2005 May ; 127(5): 1799–1804

      Edwards JG, Stewart DJ, Martin-Ucar A, Muller S, Richards C, Waller DA.

      The pattern of lymph node involvement influences outcome after extrapleural pneumonectomy for malignant mesothelioma. J Thorac Cardiovasc Surg. 2006 May;131(5):981-7.

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      WS05.05 - Lymphnode Dissection in Thymic Malignancies: Implications of the ITMIG/IASLC Lymph Node Map of the Tnm Classification and Staging (Now Available) (ID 3688)

      15:45 - 17:15  |  Presenting Author(s): Young Tae Kim  |  Author(s): In Kyu Park

      • Abstract
      • Presentation
      • Slides


      The significance of lymph node metastases and lymph node dissection (LND) remains unclear and underestimated in thymic malignancies. Given the fact that LND is an important surgical procedure for most of the solid organ malignancies, the role of LND in thymic malignancies should be established.

      The ITMIG and the IASLC proposed a new lymph node map and separated N stage in the eighth edition of TNM stage classification system for thymic malignancies. They recommended that any suspicious nodes should be routinely removed. For stage I or II thymoma, adjacent nodes as well as anterior mediastinal nodes should be removed, and for stage III thymoma, systematic anterior mediastinal node dissection and systematic sampling of appropriate intrathoracic nodes were recommended. For the thymic carcinoma, a systematic sampling of anterior mediastinal, intrathoracic, supraclavicular, and lower cervical nodes were recommended. However, there is no prospective study to validate such recommendations as these recommendations are based on the old map and old staging system. As a consequence, a revised recommendation based on a new map and a new staging system is necessary.

      Four aspects should be considered with regards to the appropriate LND during thymectomy. The first aspect is an indication. In what circumstances, the LND should be performed?. The second one is the lymph node stations to be dissected. Proper understanding of lymphatic pathway in thymus would be helpful to select lymph node to dissect. The third aspect is the adequate number of the lymph node to dissect. Often time, the quality of LND is evaluated by the number of the dissected lymph node. The last aspect is the surgical approach. It is sometimes challenging to dissect every nodal station by means of minimally invasive surgery.

      What are the surrogate markers to predict lymph node metastasis in thymic malignancies? In many studies, histologic type and T stage have been reported as predictors of lymph node metastasis. Lymph node metastasis is more frequent in thymic carcinoma and carcinoid compared with that in thymoma. Also, it is frequent in tumors invading adjacent structures (T2 or T3).

      Which lymph nodes stations are essential to dissect? Murakami et al. reported that the main lymphatic flow is a cranial direction to the cervical area, and they nicely described that the right paratracheal node group is the largest collecting area. In our group, we found that the right paratracheal lymph node station is the most common area of lymph node metastasis among deep regional node groups.

      Can we score adequacy of LND in thymic malignancies? Our group previously showed that lymph node dissection more than 10 nodes predict prognosis better. When we divided patients into N0a when LND less than 10 were performed, N0b when LND was performed more than 10, and Nx when no LND was performed, the prognosis of N0a group was inferior to N0b and was similar to Nx group.

      In our recent paper, we reviewed 131 thymic malignancy patients who underwent LND using 8th TNM staging and ITMIG Lymph node map. Lymph node metastasis was detected in 13 patients (N1 in six and N2 in seven). Six N2 patients (86%) had right paratracheal node metastases. The rates of node metastasis were 1% in T1 as compared to 37.5% in T2 or T3 (p < 0.001). The rates of node metastasis were 8% in the M0 as compared to 43% in the M1 (p = 0.03). The rate was higher in thymic carcinoma (25%) than in thymoma (5.1%, p = 0.01), and the rates also differed between the subtypes of thymoma. There was no node metastasis of the A, AB, or B1 histologic subtypes. Tumor size was also a significant factor which can predict node metastasis. The optimal cutoff value for the node metastasis was 6 cm, and the specificity was 62%. Only 16% of the patients had received a preoperative histologic diagnosis. All patients with node metastasis had cTNM stage II or higher thymic malignancy. The freedom from recurrence rate of the pN1 or pN2 was significantly worse than that of the pN0 (5-year rate 38.5% versus 87.9%, p < 0.001).

      Based on the previously mentioned information, we proposed a revised recommendation for LND in thymic malignancies. For N1, peri-thymic, prevascular, and supradiaphragmatic lymph nodes should be included as a routine en-bloc dissection. Lower cervical lymph nodes and paraaortic nodes should be either sampled or dissected, especially in c-stage II or higher. For right paratracheal N2 nodes, sampling for c-stage I, dissection for c-stage II or higher is recommended. For other N2 nodes, sampling is recommended in c-stage II or higher, or in thymic carcinoma.

      Almost all of the anterior regional nodes can be dissected during total thymectomy. During MIS, the paratracheal node can be dissected via right side approach. The paraaortic and subaortic nodes can be dissected via left side approach. The cervical lymph node can be dissected by adding cervical approach if it is necessary. However, the routine dissection of the cervical node is not recommended. A bilateral approach may be recommended, especially if the left side is chosen for the resection of the primary tumor.

      In summary, LND is recommended in locally advanced thymoma and thymic carcinoma. As the frequent metastatic stations are peri-thymic and right paratracheal lymph nodes, LND of these stations are necessary. LND may be possible during minimally invasive surgery, and the bilateral approach may be recommended in tumors with higher than T2, especially in left-sided tumors.


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      WS05.06 - Relevance of Lymphadenectomy in Carcinoma of the Esophagus and of the Esophagogastric Junction (Now Available) (ID 3689)

      15:45 - 17:15  |  Presenting Author(s): Gail Darling

      • Abstract
      • Presentation
      • Slides


      Historically surgeons thought that removal of lymph nodes was unimportant as esophagectomy was viewed as a palliative operation. As more patients survive their surgery, overall survival has become an important goal. Does lymphadenectomy contributes to improved survival? The optimum lymphadenectomy has two components: required nodal resection for accurate staging and required nodal resection for optimizing survival.

      Number of resected nodes required for accurate staging

      In patients who have 8 metastatic nodes, removing more nodes doesn’t change prognosis or improve survival. However in early stage disease, resection of a high number of nodes is required to be certain that the patient is truly N0. Using the WECC database, Rice reported that for short (<2.5cm), well differentiated and superficial cancers, >60 resected nodes are required to be certain that the patient is truly N0 [1]. A minimum of >12 resected nodes is required to achieve >90% sensitivity in staging accuracy [2] and Rizk identified that if > 18 nodes are resected the T stage is no longer prognostic [3].

      The International Society for Diseases of the Esophagus consensus conference recommended that the minimum number of nodes required for accurate staging is 15 and this remains the current recommendation of the NCCN [4]. Patients with < 15 nodes resected are less likely to have nodal metastases identified and there is a survival benefit when > 15 nodes are resected, suggesting that with < 15 resected nodes, patients are understaged [5,6,7 ]. Further, with less than 15 nodes examined, N0 vs. N1 becomes the deciding factor in prognosis [8]. Patients who had a transhiatal esophagectomy, or had < 16 nodes resected or were pN1 had similar median survival (13, 14, 12 months respectively) compared to those who have a transthoracic resection ( 24 months), or were pN0 (38 months) or had> 16 nodes resected ( 25 months)[9].

      Number of resected nodes required to optimize survival

      Rizk reported that the optimal number of resected nodes varies based on pT stage. For pT1 tumors only 10 nodes are required whereas for pT2 20 nodes but ≥ 30 nodes are required for pT3/4 tumors [10]. However Greenstein reported that survival was improved if > 10 nodes were removed for cT2-3N0 patients but > 18 nodes for cT1N0 [11]. Altorki reported that the number of nodes required to impact survival depended on N status. Survival increases with number of nodes removed but for N1 patients removal of > 17 nodes was required but for N0 patients resection of > 40 nodes was required to improve survival [12]. Using the SEER database, > 30 resected nodes are required to optimize survival [13, 14].

      Samson, using the NCDB, compared mortality between patients who met the NCCN guideline of removing ≥ 15 nodes vs those who had < 15 nodes removed. Removal of >15 nodes was associated with lower mortality and the optimum threshold identified was 25 nodes [15]. Peyre also identified that removal of 23 nodes was the optimum threshold for surviva [16]. However, studies by Lagergren report no benefit to increased lymph node removal[17,18].

      The minimum number of resected nodes required is 15 however, but the number required to optimize survival is 23-30.

      Required Nodal stations for resection and the relevance of tumor location and histology

      The lymphatics of the esophagus run longitudinally in the submucosa as well as draining horizontally into regional lymph nodes or directly into the thoracic duct. Akiyama reported that tumors of the upper third of the esophagus could have lymph node metastases from the upper mediastinum to the upper abdomen. Tumors of the lower third of the esophagus most commonly had lymph node metastases near the celiac and left gastric artery but also in the infracarinal mediastinum. The 8th edition of the AJCC staging manual identified all nodes as regional nodes. Thus all regional lymph nodes should be resected including the upper abdominal nodes and mediastinal nodes. This applies to tumors of all histogies.

      The effect of induction therapy on lymph node harvest suggests that preoperative chemoradiation may reduce the number of lymph nodes harvested [ 20,21] , however in the CROSS trial there was no difference in lymph node harvest [22].


      Lymphadenectomy is important in esophagectomy for cancer with regard to staging accuracy but also contributes to survival. The more nodes examined, the higher the accuracy of N staging. The number needed to ensure accurate N stage for early cancers ranges from 40 to 60 nodes for T1 cancers, while the minimum number for all cancers is 15 nodes. Resection of < 15 nodes understages patients and compromises survival. The more nodes removed, the better the survival. However the optimum threshold appears to be 23-30 nodes. An important consideration is that all nodes are considered regional nodes and should be resected as a key component of esophagectomy for cancer.


      1. Rice. Ann Surg. 2017; 265: 122–129.

      2. Dutkowski. Hepatogastroenterology 2002; 49: 176-180.

      3. Rizk J Thorac Cardiovasc Surg. 2006;132:1374 –1381.

      4. Fumagalli. Dis Esophagus 1996; 9: S30-S38.

      5. Barbour. Ann Surg Oncol 2007; 14: 306-316.

      6. Gu Cancer 2006; 106: 1017-1025.

      7. Bollschweiler J Surg Oncol 2006; 94: 355-363

      8. van Sandick J Am Coll Surg 2002; 194: 28-36.

      9. Junginger. Eur J Surg Oncol. 2006; 32:749-55.

      10. Rizk Ann Surg 2010; 251: 46–50

      11. Greenstein. J Am Coll Surg 2008; 206: 239-246

      12. Altorki. Ann Surg 2008; 248: 221-226

      13. Groth. JTCVS 2010; 139 612-620

      14. Schwarz. J Gastrointest Surg 2007; 11: 1384-1393

      15. Samson. Ann Thor Surg 2016; 101: 2102-2111

      16. Peyre. Ann Surg 2008; 248: 549-556.

      17. Lagergren. JAMA Surg 2016; 151: 32-39,

      18.Van der Schaaf J Natl Cancer Inst 2015: 107

      19. Akiyama. Ann Surg 1981; 194; 438- 446

      20. Samson. Ann Thor Surg 2017;103: 406-415

      21. Marriette. Ann Surg 2008;247: 3565-371

      22. Oppedijk. J Clin Onc 2014;32: 385-391

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