Is there a role for radical esophagectomy.

The aim of primary surgery in the treatment of carcinoma of the esophagus and gastroesophageal junction (GEJ) is definite cure. To obtain this goal R0 resection, i.e. complete macroscopic and microscopic removal is of paramount 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 third field). Three arguments are believed to favour more extended lymphadenectomy: optimal staging, prolonged tumour control, improved cure rate. (a) Optimal staging: available data indicate that unforeseen lymph node involvement in the neck is encountered in approximately 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 positive nodes in the neck. (b) Prolonged tumour control: radical esophagectomy and extensive lymphadenectomy is decreasing locoregional recurrence substantially, below 10%, in several published reports. More over extended lymphadenectomy seems to defer onset of locoregional recurrence and generalised metastasis 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 lymphadenectomy offers the best chances for prolonged survival or cure. This can be done without increasing hospital mortality and morbidity. Survival figures 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.