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The esophagus traverses the neck, mediastinum, and abdomen. Cancer of the thoracic esophagus can metastasize to lymph nodes and locate in any or all of these compartments.1 The rate of lymph node involvement is very high. Approximately 50% of tumors that invade the submucosa develop lymph node metastases, and the rate increases with increasing depth of invasion. Radical surgery for esophageal cancer therefore requires three-field lymphadenectomy. Our group has been performing three-field lymph node dissections since 1984 for all thoracoesophageal cancers. In this chapter we lay down the principles, describe the procedure, and discuss the outcome of this mode of treatment based on our experience.

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The overall 5-year survival rate for squamous cell carcinoma of the esophagus has improved from 20% to 50%. We believe this improvement in survival can be directly related to extensive and meticulous lymphadenectomy.2 This view has been corroborated by multivariate analysis. The key to three-field lymphadenectomy therefore is meticulous dissection of the upper mediastinum and cervical nodes that lie along the course of both recurrent laryngeal nerves. Preserving the right bronchial artery and pulmonary branches of the vagus nerve decreases the rate of pulmonary complications. Using this comprehensive approach, we have achieved a postoperative mortality rate of less than 2%.

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Esophageal cancer is more aggressive biologically than other gastrointestinal malignancies and has a higher incidence of lymph node metastasis.3 Lymph node metastasis is an important and independent factor for predicting the prognosis of esophageal cancer. The number of metastatic lymph nodes is thought to reflect the aggressiveness of the cancer.4 Accurate documentation of the extent of lymph node involvement therefore is essential to determining the appropriate treatment strategy for esophageal cancer.

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Histopathologic assessment remains the gold standard for accurate lymph node staging. Proper assessment also requires that an adequate number of lymph nodes be presented to the pathologist. Since 1984, all tumors determined to have invasion of the submucosa or beyond undergo three-field dissection at our institution. Three-field dissection is defined as an extended en-bloc lymph node dissection throughout the cervical, thoracic, and abdominal fields.5

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A total of 251 patients underwent transthoracic esophagectomy with extended en-bloc cervicothoracoabdominal (three-field) lymphadenectomy between January 1998 and December 2002 at Juntendo University in Japan. A total of 27,774 lymph nodes were dissected, and the average number of dissected lymph nodes per patient was 111. The lymph nodes removed en bloc with the specimen were dissected and classified into respective lymph node groups immediately after the operation by the surgeons who performed the esophagectomy, as outlined in the Japanese Guidelines for Clinical and Pathologic Studies on Classification of Esophageal Cancer6 (Fig. 18-1). This provides a more detailed lymph node classification than the AJCC Cancer Staging Manual.7 The pattern of lymphatic spread was investigated in detail, and the final pathologic diagnosis of lymph node metastasis was compared with the preoperative clinical evaluation to assess the accuracy of ...

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