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Fan B, Sun Z, Lu J, Liu J, Zhao J, Zhou S, Di S, Song W, Gong T. Three-Field Versus Two-Field Lymphadenectomy in Minimally Invasive Esophagectomy: 3-Year Survival Outcomes of a Randomized Trial. Ann Surg Oncol 2023; 30:6730-6736. [PMID: 37358684 DOI: 10.1245/s10434-023-13748-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 06/01/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Minimally invasive esophagectomy (MIE) has been used widely for the treatment of esophageal cancer. However, the optimal extent of lymphadenectomy for esophagectomy in MIE remains unclear. This trial aimed to investigate the 3-year survival and recurrence outcomes in a randomized controlled trial comparing MIE with either three-field lymphadenectomy (3-FL) or two-field lymphadenectomy (2-FL). METHODS Between June 2016 and May 2019, 76 patients with resectable thoracic esophageal cancer were enrolled in a single-center randomized controlled trial and randomly assigned to MIE that included either 3-FL or 2-FL at a 1:1 ratio (n = 38 patients each). The survival outcomes and recurrence patterns were compared between the two groups. RESULTS The 3-year cumulative overall survival (OS) probability was 68.2 % (95 % confidence interval [CI], 52.72-83.68 %) for the 3-FL group and 68.6 % (95 % CI, 53.12-84.08 %) for the 2-FL group. The 3-year cumulative probability of disease-free survival (DFS) was 66.3 % (95 % CI, 50.03-82.57 %) for the 3-FL group and 67.1 % (95 % CI, 51.03-83.17 %) for the 2-FL group.. The OS and DFS differences in the two groups were comparable. The overall recurrence rate did not differ significantly between the two groups (P = 0.737). The incidence of cervical lymphatic recurrence in the 2-FL group was higher than in the 3-FL group (P = 0.051). CONCLUSIONS Compared with 2-FL in MIE, 3-FL tended to prevent cervical lymphatic recurrence. However, it was not found to add survival benefit for the patients with thoracic esophageal cancer.
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Affiliation(s)
- Boshi Fan
- Department of Thoracic Surgery, The Sixth Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Zengfeng Sun
- Department of Thoracic Surgery, The Sixth Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Jing Lu
- Department of Thoracic Surgery, The Sixth Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - JunQiang Liu
- Department of Thoracic Surgery, The Sixth Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Jiahua Zhao
- Department of Thoracic Surgery, The Sixth Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Shaohua Zhou
- Department of Thoracic Surgery, The Sixth Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Shouyin Di
- Department of Thoracic Surgery, The Sixth Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Weian Song
- Department of Thoracic Surgery, The Sixth Medical Center of Chinese, PLA General Hospital, Beijing, China.
| | - Taiqian Gong
- Department of Thoracic Surgery, The Sixth Medical Center of Chinese, PLA General Hospital, Beijing, China.
- The Second Clinical College of Southern Medical University, Guangzhou, China.
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Zeng T, Chen M, Cai B, Zheng W, Xu C, Xu G, Chen C, Zheng B. How to distinguish thoracic and cervical lymph nodes during minimally invasive esophagectomy. Thorac Cancer 2022; 13:2436-2442. [PMID: 35852040 PMCID: PMC9436676 DOI: 10.1111/1759-7714.14554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/06/2022] [Accepted: 06/09/2022] [Indexed: 12/01/2022] Open
Abstract
Purpose In this article, we aimed to reconstruct the cervical–thoracic junction plane (CTJP) using a three‐dimensional (3D) reconstruction system. Thus, the CTJP can be judged during surgery to better distinguish cervical–thoracic lymph nodes. Methods We included patients in Fujian Medical University Union Hospital from December 2019 to March 2020. All patients underwent a thin‐slice and enhanced computed tomography scan of the chest with 3D reconstruction using the IQQA system (EDDA technology) to reconstruct the CTJP, brachiocephalic trunk, right common carotid artery, and right subclavian artery. The distance from the intersection of the right subclavian artery and the CTJP to the origin of the right subclavian artery (ORSA) was measured, and the relationship between this distance and the patient's sex, BMI and height was analyzed. Results Seventy‐three patients were enrolled, of whom 12 had ORSA above the CTJP, while 61 had ORSA below the plane. There was a significant difference in age between the two groups (p = 0.04), compared with height, weight and BMI (p > 0.05). In 61 patients with the ORSA below the CTJP, the average distance was 24.7 ± 7.6 mm. The difference between the distance and BMI (p = 0.02) was statistically significant, and it was increased with increasing BMI. Conclusions The relationship between the ORSA and CTJP can be clarified through 3D reconstruction. The cervical‐thoracic recurrent laryngeal nerve lymph nodes can be distinguished clearly in minimally invasive esophagectomy, contributing to the accurate N staging of middle‐thoracic esophageal cancer.
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Affiliation(s)
- Taidui Zeng
- Key labortatory of Cardio‐Thoracic Surgery (Fujian Medical university), Fujian Province University Fuzhou China
- Department of Thoracic Surgery Fujian Medical University Union Hospital Fuzhou China
| | - Maohui Chen
- Key labortatory of Cardio‐Thoracic Surgery (Fujian Medical university), Fujian Province University Fuzhou China
- Department of Thoracic Surgery Fujian Medical University Union Hospital Fuzhou China
| | - Bingqiang Cai
- Key labortatory of Cardio‐Thoracic Surgery (Fujian Medical university), Fujian Province University Fuzhou China
- Department of Thoracic Surgery Fujian Medical University Union Hospital Fuzhou China
| | - Wei Zheng
- Key labortatory of Cardio‐Thoracic Surgery (Fujian Medical university), Fujian Province University Fuzhou China
- Department of Thoracic Surgery Fujian Medical University Union Hospital Fuzhou China
| | - Chi Xu
- Key labortatory of Cardio‐Thoracic Surgery (Fujian Medical university), Fujian Province University Fuzhou China
- Department of Thoracic Surgery Fujian Medical University Union Hospital Fuzhou China
| | - Guobing Xu
- Key labortatory of Cardio‐Thoracic Surgery (Fujian Medical university), Fujian Province University Fuzhou China
- Department of Thoracic Surgery Fujian Medical University Union Hospital Fuzhou China
| | - Chun Chen
- Key labortatory of Cardio‐Thoracic Surgery (Fujian Medical university), Fujian Province University Fuzhou China
- Department of Thoracic Surgery Fujian Medical University Union Hospital Fuzhou China
| | - Bin Zheng
- Key labortatory of Cardio‐Thoracic Surgery (Fujian Medical university), Fujian Province University Fuzhou China
- Department of Thoracic Surgery Fujian Medical University Union Hospital Fuzhou China
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3
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Yan HJ, Mao WJ, Yu RX, Jiang KY, Huang H, Zong ZD, Qian QC, Guo XG, Wen HY, Tian D. Preoperative Clinical Characteristics Predict Recurrent Laryngeal Nerve Lymph Node Metastasis and Overall Survival in Esophageal Squamous Cell Carcinoma: A Retrospective Study With External Validation. Front Oncol 2022; 12:859952. [PMID: 35433473 PMCID: PMC9008727 DOI: 10.3389/fonc.2022.859952] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/07/2022] [Indexed: 02/05/2023] Open
Abstract
Background Recurrent laryngeal nerve (RLN) lymph node metastasis (LNM) is not rare in patients with esophageal squamous cell carcinoma (ESCC). We aimed to develop and externally validate a preoperative nomogram using clinical characteristics to predict RLN LNM in patients with ESCC and evaluate its prognostic value. Methods A total of 430 patients with ESCC who underwent esophagectomy with lymphadenectomy of RLN LNs at two centers between May 2015 and June 2019 were reviewed and divided into training (center 1, n = 283) and external validation cohorts (center 2, n = 147). Independent risk factors for RLN LNM were determined by multivariate logistic regression, and a nomogram was developed. The performance of the nomogram was assessed in terms of discrimination, calibration, clinical usefulness, and prognostic value. The nomogram was internally validated by the bootstrap method and externally validated by the external validation cohort. Results Multivariate analysis indicated that clinical T stage (P <0.001), endoscopic tumor length (P = 0.003), bioptic tumor differentiation (P = 0.004), and preoperative carcinoembryonic antigen level (P = 0.001) were significantly associated with RLN LNM. The nomogram had good discrimination with the area under the curve of 0.770 and 0.832 after internal and external validations. The calibration curves and decision curve analysis confirmed the good calibration and clinical usefulness of this model. High-risk of RLN LNM predicted by the nomogram was associated with worse overall survival in the external validation cohort (P <0.001). Conclusion A nomogram developed by preoperative clinical characteristics demonstrated a good performance to predict RLN LNM and prognosis for patients with ESCC.
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Affiliation(s)
- Hao-Ji Yan
- Department of Cardiothoracic Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China.,College of Medical Imaging, North Sichuan Medical College, Nanchong, China
| | - Wen-Jun Mao
- Department of Cardiothoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Rui-Xuan Yu
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Kai-Yuan Jiang
- Department of Cardiothoracic Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Heng Huang
- Department of Cardiothoracic Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Zheng-Dong Zong
- College of Clinical Medicine, North Sichuan Medical College, Nanchong, China
| | - Qin-Chun Qian
- College of Clinical Medicine, North Sichuan Medical College, Nanchong, China
| | - Xiao-Guang Guo
- Department of Pathology, Nanchong Central Hospital, Nanchong, China
| | - Hong-Ying Wen
- Department of Cardiothoracic Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Dong Tian
- Department of Cardiothoracic Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
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Yan Z, Xu X, Lu J, You Y, Xu J, Xu T. Development and validation of a nomogram for prediction of cervical lymph node metastasis in middle and lower thoracic esophageal squamous cell carcinoma. BMC Gastroenterol 2022; 22:163. [PMID: 35369868 PMCID: PMC8978436 DOI: 10.1186/s12876-022-02243-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 03/28/2022] [Indexed: 01/03/2023] Open
Abstract
Abstract
Background
Estimates of cervical lymph node (LN) metastasis in patients with middle and lower thoracic esophageal squamous cell carcinoma (ESCC) are important. A nomogram is a useful tool for individualized prediction.
Methods
A total of 235 patients were enrolled in this study. Univariate and multivariate analyses were performed to screen for independent risk factors and construct a nomogram to predict the risk of cervical LN metastasis. The nomogram performance was assessed by discrimination, calibration, and clinical use.
Results
Totally, four independent predictors, including the maximum diameter of tumor, paraesophageal lymph node status, recurrent laryngeal nerve lymph node status, and the CT-reported cervical LN status, were enrolled in the nomogram. The AUC of the nomogram model in the training and validation dataset were 0.833 (95% CI 0.762–0.905), 0.808 (95% CI 0.696–0.920), respectively. The calibration curve demonstrated a strong consistency between nomogram and clinical findings in predicting cervical LN metastasis. Decision curve analysis demonstrated that the nomogram was clinically useful.
Conclusion
We developed a nomogram that could be conveniently used to predict the individualized risk of cervical LN metastasis in patients with middle and lower thoracic ESCC.
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Tu DH, Qu R, Ping W, Yang G, Ma X, Fu X, Cai Y. Double-lumen tube versus bronchial blocker in lymphadenectomy along the left recurrent laryngeal nerve for esophageal cancer: a propensity-matched analysis. Langenbecks Arch Surg 2022; 407:1891-1900. [PMID: 35314875 DOI: 10.1007/s00423-022-02475-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 02/15/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lymph node (LN) dissection along left recurrent laryngeal nerve (RLN) is challenging in esophagectomy for esophageal cancer, and double-lumen endotracheal tube (DLT) impedes the exposure of this area. The aim of this study was to determine whether bronchial blockers (BB) could be a better choice for this procedure. METHODS The clinical characteristics of patients who received McKeown esophagectomy with radical lymph node dissection in Wuhan Tongji Hospital between August 2017 and July 2019 were retrospectively analyzed. The 1:1 propensity score match analysis was performed to compare the short-term effectiveness, the numbers of lymph nodes dissected, and the patterns of recurrence and survival between the two groups. RESULTS A total of 294 patients (192 and 102 in the DLT and BB group, respectively) were enrolled in the study. After matching, 204 patients (102 pairs) who underwent one-lung ventilation with DLT or BB displayed no significant variance in baseline characteristics. The BB group had higher number of LNs resected along left RLN (1.8 ± 2.3 vs. 2.5 ± 2.5, P = 0.001). For patients with metastatic left RLN LN, the BB group had longer medium survival time (15 vs. 32 months, P = 0.045), and tended to have longer medium recurrence-free survival time (6 vs. 15 months, P = 0.079), and lower rate of upper mediastinal and cervical LN recurrence (30.00% vs. 66.67%, P = 0.198). The postoperative complications were similar in both groups. CONCLUSIONS Compared with DLT, using BB in esophagectomy may allow more radical lymphadenectomy along left RLN.
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Affiliation(s)
- De-Hao Tu
- Department of Thoracic Surgery, Tongji Hospital Tongji Medical College, Huazhong University of Science and Technology, 1095 Jie Fang Avenue, Wuhan, 430030, China
| | - Rirong Qu
- Department of Thoracic Surgery, Tongji Hospital Tongji Medical College, Huazhong University of Science and Technology, 1095 Jie Fang Avenue, Wuhan, 430030, China
| | - Wei Ping
- Department of Thoracic Surgery, Tongji Hospital Tongji Medical College, Huazhong University of Science and Technology, 1095 Jie Fang Avenue, Wuhan, 430030, China
| | - Guang Yang
- Department of Thoracic Surgery, Tongji Hospital Tongji Medical College, Huazhong University of Science and Technology, 1095 Jie Fang Avenue, Wuhan, 430030, China
| | - Xiaoling Ma
- Department of Radiology, Tongji Hospital Tongji Medical College Huazhong University of Science and Technology, Wuhan, China
| | - Xiangning Fu
- Department of Thoracic Surgery, Tongji Hospital Tongji Medical College, Huazhong University of Science and Technology, 1095 Jie Fang Avenue, Wuhan, 430030, China.
| | - Yixin Cai
- Department of Thoracic Surgery, Tongji Hospital Tongji Medical College, Huazhong University of Science and Technology, 1095 Jie Fang Avenue, Wuhan, 430030, China.
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Zhang G, Li Y, Wang Q, Zheng H, Yuan L, Gao Z, Li J, Li X, Zhao S. Development of a prediction model for the risk of recurrent laryngeal nerve lymph node metastasis in thoracolaparoscopic esophagectomy with cervical anastomosis. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:990. [PMID: 34277790 PMCID: PMC8267307 DOI: 10.21037/atm-21-2374] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/09/2021] [Indexed: 12/14/2022]
Abstract
Background There are no effective preoperative diagnostic measures to predict the probability of left and right recurrent laryngeal nerve (RLN) lymph node (LN) metastasis using preoperative clinical data in patients undergoing thoracolaparoscopic esophagectomy with cervical anastomosis. Methods We retrospectively reviewed the clinical data of 1,660 consecutive patients with thoracic esophageal cancer who underwent esophagectomy with cervical anastomosis at the Department of Thoracic Surgery at the First Affiliated Hospital of Zhengzhou University between January 2015 and December 2020. Results A total of 299 and 343 patients who underwent left (Cohort 1) and right (Cohort 2) RLN LN dissection were included in the final analyses. The analyses were conducted within each cohort. Among the 299 patients in Cohort 1, left RLN LN involvement was found in 41 patients (13.7%). A multivariable analysis showed that age, tumor location, and short axis were significantly associated with RLN LN metastasis (all P<0.05). Among the 343 patients in Cohort 2, right RLN LN involvement was found in 65 patients (19.0%). A multivariable analysis showed that computed tomography (CT) appearance, tumor location, long axis, and short axis were significantly associated with RLN LN metastasis (all P<0.05). Based on the results of the multivariable analyses, we constructed nomograms that could estimate the probability of RLN LN metastasis. Finally, we stratified the 2 cohorts into risk subgroups using a recursive partitioning analysis (RPA). The risk of left and right RLN LN metastasis was found to be 9.3% and 7.5%, 27.3% and 21.4%, and 52.4% and 47.3% for the low-risk, intermediate-risk, and high-risk groups, respectively. Conclusions Our nomograms and RPAs appear to be suitable for the risk stratification of left and right RLN LN metastasis in patients undergoing thoracolaparoscopic esophagectomy with cervical anastomosis. This tool could be used to help clinicians to select more effective locoregional treatments, such as surgical protocols and radiation area selection.
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Affiliation(s)
- Guoqing Zhang
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuanqi Li
- Xiangya School of Public Health, Central South University, Changsha, China
| | - Qian Wang
- The Nursing Department, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Huiwen Zheng
- The Nursing Department, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lulu Yuan
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhen Gao
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jindong Li
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiangnan Li
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Song Zhao
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Zhang Y, Chen M, Xiao J, Liang M, Zheng W, Chen C, Zheng B. Postoperative follow-up strategy based on event dynamics for esophageal squamous cell carcinoma. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:699. [PMID: 33987397 PMCID: PMC8106059 DOI: 10.21037/atm-21-1373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Despite the improvements in radical surgery for esophageal squamous cell carcinoma (ESCC), a large number of patients still develop recurrence. This research sought to graphically depict patterns in ESCC recurrence following curative surgical treatment using event dynamics and clarify approaches to postsurgical follow-up on the basis of recurrence time. Methods This study included 717 individuals with ESCC who received radical surgery in the Thoracic Department at Fujian Medical University Union Hospital between 2013 and 2016. Event dynamics analysis was performed on the basis of hazard rates. An initial event was defined as the occurrence of local recurrence, distant metastasis, or both. Results After complete resection, patients were followed up for a median of 44 months (range, 2–83 months). A total of 223 (31.1%) patients developed recurrence, including 122 (17.0%) patients who developed only locoregional recurrence, and 101 (14.1%) patients who developed only distant metastasis or both locoregional recurrence and distant metastasis. Recurrences were concentrated mainly (98.2%) in the first 4 years of follow-up among all recurrences, with 100 cases (44.8%) in the first year, 69 cases (30.9%) in the second year, and 50 cases (22.4%) in the third and fourth years. Conclusions After curative surgery in a multimodal setting, a significant number of patients still experienced recurrence within 4 years after surgery, which suggests that current postoperative esophageal cancer follow-up strategies may need to be modified.
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Affiliation(s)
- Yongcong Zhang
- Department of Thoracic Surgery, Quanzhou First Hospital, Fujian, China.,Fujian Key Laboratory of Cardiothoracic Surgery (Fujian Medical University), Fuzhou, China
| | - Maohui Chen
- Fujian Key Laboratory of Cardiothoracic Surgery (Fujian Medical University), Fuzhou, China.,Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jiazhou Xiao
- Fujian Key Laboratory of Cardiothoracic Surgery (Fujian Medical University), Fuzhou, China.,Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Mingqiang Liang
- Fujian Key Laboratory of Cardiothoracic Surgery (Fujian Medical University), Fuzhou, China.,Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Wei Zheng
- Fujian Key Laboratory of Cardiothoracic Surgery (Fujian Medical University), Fuzhou, China.,Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Chun Chen
- Fujian Key Laboratory of Cardiothoracic Surgery (Fujian Medical University), Fuzhou, China.,Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Bin Zheng
- Fujian Key Laboratory of Cardiothoracic Surgery (Fujian Medical University), Fuzhou, China.,Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
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Udagawa H. Past, present, and future of three-field lymphadenectomy for thoracic esophageal cancer. Ann Gastroenterol Surg 2020; 4:324-330. [PMID: 32724875 PMCID: PMC7382429 DOI: 10.1002/ags3.12338] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 02/28/2020] [Accepted: 03/22/2020] [Indexed: 12/14/2022] Open
Abstract
In spite of repeated appeal of the effectiveness of three-field lymphadenectomy (3FL) by Japanese esophageal surgeons, it has not been accepted worldwide as a standard therapeutic measure for thoracic esophageal cancer. In this review, a concise summary of the history of 3FL, its present position, and its future perspective is discussed. Although a lack of randomized controlled trial (RCT) is one of the largest criticisms of 3FL, it seems difficult to make 3FL world-standard even if a RCT with a positive result was made. The essence of 3FL has revealed the fact that bilateral cervical paraesophageal nodes and nodes in the bilateral supraclavicular fossae are regional nodes of thoracic esophageal cancer. To let the world admit this essence should be the real endpoint of "3FL issue" without RCT. In the era of new modalities, Japanese surgeons should be free from the idea that 3FL is indispensable though the essence of 3FL should remain.
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Affiliation(s)
- Harushi Udagawa
- Toranomon Hospital KajigayaKawasaki CityJapan
- Okinaka Memorial Institute for Medical ResearchTokyoJapan
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