Preoperative nodes’ staging in oesophageal cancer: do more with less? Free

Accurate lymph node staging for oesophageal cancer is still under discussion and whether the number or the region is more important. Optimizing lymph node assessment remains a crucial aspect of oesophageal cancer management to improve prognosis and treatment strategies.

The oesophagus has abundant lymphatic routes in the submucosal layer and to regulate the extent of nodes’ metastasis in oesophageal cancer, a strategy for extended nodes’ dissection has been established: the 3 field nodes’ dissection was developed in the 1980s in Japan and it is accepted worldwide as the standard [1].

The literature suggests that examining a higher number of lymph nodes after oesophagectomy for oesophageal cancer is associated with improved survival outcomes. This underscores the importance of lymph node dissection and pathological examination in accurately staging the disease and then guiding treatment decisions [2].

Several studies have already tried to define the correct number of lymph nodes to be removed for this purpose. N metastasis primarily occurs from the cervix to the abdominal field. Based on previous studies, the range of the dissection can be determined considering primary tumour’s location, progression, histology and perioperative treatment. In the 3 field nodes’ dissection, nodes from the cervix to the abdomen are routinely dissected and it includes: supraclavicular nodes, paracervical oesophageal nodes, around the bilateral recurrent laryngeal nerve, paraoesophageal, paratracheal, posterior mediastinic and supradiaphragmatic. In the abdominal field, 3 field nodes’ dissection includes: paracardiac, nodes along the lesser curvature, nodes along the trunk of the left gastric artery, nodes around the abdominal oesophagus and infradiaphragmatic [3, 4].

The impact of extended nodes’ dissection in postoperative complications have been already described in the work by Uimonen et al. ‘Optimal lymph node yield in oesophagectomy for oesophageal cancer: a nationwide population-based study’ [5].

The destructive effects on patients’ quality of life after surgery, especially the risk after extent dissection, are well known and postoperative complications were shown to worsen the prognosis of patients with oesophageal cancer. In order to improve the cure rate and postoperative quality of life, more attention should be paid to individualized treatment [6]. The intraoperative identification of sentinel lymph node and its biopsy is an attractive alternative to standard extensive dissection. In fact, this method of identification can be used for personalized lymph node dissection in oesophageal squamous cell carcinoma. Takeuchi et al. reported the mapping of the sentinel lymph node [7].

In the era of minimally invasive, the question is how an accurate and complete diagnosis can be achieved, reducing risks for the patient, and obtaining the same oncological results in terms of prognosis and survival.

While surgical resection and examination of lymph nodes remain the gold standard for accurate staging, endoscopic ultrasound with fine-needle aspiration or biopsy can provide valuable information about the presence of lymph node involvement before surgery. This minimally invasive technique can help determine the presence of metastatic disease, guide treatment decisions and potentially spare patients from unnecessary surgery if the disease is deemed unresectable or if neoadjuvant therapy is indicated [8].

However, it is important to note that endoscopic biopsy has limitations, such as the potential for sampling error and difficulty in accessing certain lymph nodes, especially those located deep within the mediastinum and incomplete pathologic lymph node examination and under staging patients as a result can falsely worsen stage-per-stage survival. Knowing the extent of nodal involvement can also help surgeons plan the extent of lymphadenectomy during surgery.

Endoscopic biopsy results can also have predictive value in assessing response to treatment and predicting long-term outcomes. Patients with complete response to neoadjuvant therapy, as indicated by negative lymph node biopsies on follow-up, may have better prognoses than those with persistent nodal involvement.

Overall, endoscopic biopsy of lymph nodes in oesophageal cancer contributes valuable information to prognostic patient evaluation by aiding in accurate staging, guiding treatment decisions, risk stratification and predicting treatment outcomes.

Future research should be directed in risk stratifying patients based on molecular classifiers. However, beside the promising interest in sentinel lymph node utility, until the accuracy of non-invasive methods for assessing complete clinical response will develop, surgery with complete lymphadenectomy remains the gold standard [9].

This reflection aims to encourage the development of further prospective studies on mini-invasive complete nodes’ staging, to achieve effective results doing more with less: that is to say to cross actual boundaries in complete nodes’ staging, while reducing the mortality and the morbidity caused by extended intraoperative dissection.

FUNDING

This work did not receive any funding.

Conflict of interest: none declared.

DATA AVAILABILITY

The data underlying this article are available in the article and in its online supplementary material.

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