Overview
Definition:
Three-field lymphadenectomy (3F-LND) is an extensive surgical procedure for esophageal cancer that involves the removal of lymph nodes from three distinct anatomical regions: the cervical (neck), mediastinal (chest), and abdominal compartments
This approach aims to achieve a more comprehensive removal of regional lymphatic spread compared to two-field or single-field lymphadenectomy.
Epidemiology:
Esophageal cancer is a significant global health concern, with squamous cell carcinoma and adenocarcinoma being the predominant histological types
The incidence and prevalence vary geographically
Advanced staging at diagnosis often necessitates aggressive multimodal treatment, including surgery with comprehensive lymphadenectomy.
Clinical Significance:
The extent of lymph node metastasis is a critical prognostic factor in esophageal cancer
3F-LND is considered for resectable esophageal cancers, particularly those with a higher risk of extensive nodal involvement, to improve locoregional control and potentially enhance survival outcomes
Its systematic approach addresses potential skip metastases and improves staging accuracy.
Indications
Surgical Indications:
Resectable esophageal cancer (T1b-T4a N+ M0)
Tumors involving the mid and upper esophagus are generally considered better candidates for 3F-LND due to the typical lymphatic drainage patterns
Clinical T staging and nodal status assessed by imaging (CT, PET-CT) and EUS guide selection
Absence of distant metastases (M0)
Adequate patient performance status (ECOG 0-1) and cardiopulmonary reserve.
Contraindications:
Distant metastatic disease (M1)
Unresectable locally advanced disease (T4b)
Severe comorbidities precluding major surgery
Patient refusal or poor performance status
Very early-stage tumors (Tis, T1a) where less extensive nodal dissection may suffice.
Neoadjuvant Therapy Consideration:
Patients receiving neoadjuvant chemoradiotherapy may still be candidates for 3F-LND if a good response is achieved and disease remains resectable
The decision is individualized based on response assessment and tumor regression.
Preoperative Preparation
Patient Assessment:
Comprehensive assessment of cardiopulmonary function (spirometry, echocardiogram)
Nutritional status evaluation (albumin, prealbumin)
Assessment for occult metastatic disease
Multidisciplinary team discussion (surgeon, oncologist, radiologist, pathologist).
Investigations:
Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) for nodal staging
CT chest, abdomen, pelvis with contrast for staging
PET-CT scan for distant metastasis assessment
Esophagography for tumor length and relationship to structures
Bronchoscopy to rule out tracheobronchial involvement.
Informed Consent:
Detailed explanation of the procedure, including its extent, potential benefits, risks (e.g., chylothorax, recurrent laryngeal nerve injury, phrenic nerve palsy, anastomotic leak, long-term swallowing difficulties, mediastinitis, fistula formation), and alternatives.
Procedure Steps
General Approach:
Typically performed as an open procedure or minimally invasively (VATS/Robotic)
A common approach involves a laparotomy for abdominal lymphadenectomy, followed by a thoracotomy for mediastinal dissection, and often a cervical incision for the uppermost nodal stations and anastomosis.
Abdominal Dissection:
Laparotomy incision
Mobilization of the stomach
Dissection of the gastrohepatic ligament, lesser curvature lymph nodes (station 7, 8, 9), paracardiac nodes (station 1), paraesophageal nodes (station 8, 9), and nodes along the celiac axis (station 9)
Creation of a gastric tube or preparation for esophageal reconstruction.
Thoracic Dissection:
Thoracotomy incision (usually left-sided)
Mobilization of the esophagus
Dissection of mediastinal lymph nodes: lower mediastinum (station 4L/R), middle mediastinum (station 2L/R), upper mediastinum (station 2L/R), and para-aortic nodes (station 8/9)
Careful preservation of the recurrent laryngeal nerves and phrenic nerves.
Cervical Dissection:
Cervical incision
Dissection of cervical lymph nodes, including supraclavicular and mediastinal extension nodes (station 1, 2, 3)
Formation of the esophagogastric or esophago-intestinal anastomosis in the neck
Placement of drains.
Esophageal Reconstruction:
Reconstruction is typically performed using a gastric pull-up or a segment of colon or jejunum
The choice depends on the extent of resection and patient factors.
Postoperative Care
Monitoring:
Close monitoring in an intensive care unit (ICU)
Vital signs, fluid balance, oxygenation, and urine output
Pain management with patient-controlled analgesia (PCA) or epidural analgesia
Nutritional support via nasogastric feeding tube or parenteral nutrition.
Respiratory Support:
Early mobilization
Incentive spirometry
Chest physiotherapy
Weaning from mechanical ventilation as tolerated
Management of pleural effusions or pneumothorax.
Gastrointestinal Management:
Gradual introduction of oral intake after ensuring anastomotic integrity (often confirmed by barium swallow)
Management of delayed gastric emptying or ileus
Prevention of anastomotic leaks and strictures.
Drain Management:
Monitoring of drain output
Removal of drains when output is minimal and no signs of leak are present.
Complications
Early Complications:
Anastomotic leak (10-20%)
Chylothorax (2-5%)
Recurrent laryngeal nerve injury leading to vocal cord dysfunction or hoarseness (5-15%)
Phrenic nerve palsy (5-10%)
Mediastinitis
Pneumonia
Cardiac arrhythmias
Hemorrhage
Sepsis
Delayed gastric emptying.
Late Complications:
Anastomotic stricture leading to dysphagia
Chronic cough and aspiration
Dumping syndrome
Weight loss and malnutrition
Thoracic duct injury
Wound complications.
Prevention Strategies:
Meticulous surgical technique with careful nerve preservation
Intraoperative imaging (e.g., indocyanine green fluorescence) to assess blood supply
Optimal nutritional support
Prophylactic antibiotics
Early mobilization and respiratory physiotherapy
Judicious fluid management.
Prognosis
Factors Affecting Prognosis:
Histological type and grade of the tumor
Depth of invasion (T stage)
Number and location of positive lymph nodes (N stage)
Presence of distant metastases (M stage)
Completeness of surgical resection (R0 vs
R1/R2)
Patient's overall health status
Response to neoadjuvant therapy.
Outcomes:
Five-year survival rates for resectable esophageal cancer vary widely based on stage, ranging from approximately 40-60% for early stages to less than 10-20% for advanced stages
3F-LND aims to improve locoregional control and survival in appropriately selected patients, though it is associated with higher morbidity.
Follow Up:
Regular follow-up appointments are crucial
Typically involves physical examination, laboratory tests, and imaging (CT scans) every 3-6 months for the first 2-3 years, then annually thereafter
Endoscopic surveillance may also be performed
Surveillance focuses on detecting recurrence or new primary cancers and managing long-term sequelae.
Key Points
Exam Focus:
Understand the anatomical fields dissected (cervical, mediastinal, abdominal)
Recognize indications for 3F-LND versus 2F-LND
Identify common complications and their management
Recall the prognostic significance of lymph node status in esophageal cancer.
Clinical Pearls:
For upper/mid-esophageal tumors, 3F-LND is often preferred due to lymphatic drainage patterns
Careful preservation of recurrent laryngeal and phrenic nerves is paramount to minimize morbidity
Thorough preoperative assessment and multidisciplinary input are essential for optimal patient selection and outcomes.
Common Mistakes:
Inadequate lymph node sampling, leading to understaging
Aggressive dissection risking injury to vital structures without clear oncological benefit
Failure to consider patient comorbidities when deciding on the extent of surgery
Insufficient postoperative care leading to increased complications.