Lymph node analysis in esophageal resection: American College of Surgeons Oncology Group Z0060 trial

Background. The American Joint Committee on Cancer staging of esophageal cancer has been criticized for not establishing a minimum standard for lymphadenectomy, and for relying on location of nodes involved rather than their number. The objective of this study was to review the current practice of American surgeons with regard to lymph node assessment during esophageal resection. Methods. The operative and pathology reports of patients who underwent staging by computed tomography and fluorodeoxyglucose-positron emission tomography and subsequent resection for esophageal cancer (multi-institutional American College of Surgeons Oncology Group Z0060 trial) were analyzed. Results. One hundred forty-five patients underwent resection. Operative and pathology reports were unavailable in 11 patients. The results of the remaining 134 resections (Ivor-Lewis, n = 64; transhiatal, n = 59; other, n = 11) were reviewed. Overall, 13 +/- 9 (mean +/- standard deviation) lymph nodes were evaluated per patient. More lymph nodes were evaluated in patients undergoing Ivor-Lewis (15 +/- 9) than transhiatal esophagectomy (9 +/- 7; p < 0.001). The mean number of distinct lymph node stations analyzed per patient was 3 +/- 2. In 38% (51 of 134) of patients the nodes attached to the specimen were evaluated without any distinction among nodal stations. The practice of submitting named packets of nodal material resulted in 16 +/- 9 nodes per case, as opposed to the practice of submitting an entire specimen for the pathologists to dissect, which yielded 10 +/- 8 nodes (p < 0.001). Conclusions. There is considerable variability and room to improve in the extent of resection and pathologic evaluation of esophagectomy specimens. A uniform standard for esophageal cancer resection is warranted to improve the precision and value of pathologic staging.