II-2

Original Article
2

Salvage lymphadenectomy for isolated cervical lymph node

recurrence after curative resection of thoracic esophageal
squamous cell carcinoma
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USFBUNFOU DPVME QSPWJEF BO PQQPSUVOJUZ GPS DVSJOH UIFTF QBUJFOUT BOE UP PCTFSWF UIF QSPHOPTUJD GBDUPST GPS
UIF QBUJFOUT BGUFS TBMWBHF USFBUNFOU
CR MM QBUJFOUT XJUI &4 XIP VOEFSXFOU FTPQIBHFDUPNZ XJUI MZNQIBEFOFDUPNZ BOE XIP
XFSF EJBHOPTFE XJUI B SFMBQTF JO UIF DFSWJDBM OPEFT CFUXFFO UP MM DBTFT SFDFJWFE TBMWBHF
MZNQIBEFOFDUPNZ QMVT BEKVWBOU SBEJPUIFSBQZ DIFNPUIFSBQZ 5IFJS DMJOJDBM DIBSBDUFSJTUJDT BOE PVUDPNFT
XFSF BOBMZTFE
R K R UPUBM PG QBUJFOUT XFSF EJBHOPTFE XJUI SFDVSSFODF JO UIF DFSWJDBM OPEFT BGUFS FTPQIBHFDUPNZ
NPOH UIFTF QBUJFOUT SFMBQTFE NPOUIT BGUFS FTPQIBHFDUPNZ BOE SFDVSSFODFT
XFSF GPVOE NPOUIT MBUFS 4PMJUBSZ DFSWJDBM OPEF SFDVSSFODF XBT GPVOE JO QBUJFOUT XIJMF
DBTFT TIPXFE NVMUJQMF OPEF SFMBQTF JGUZ GPVS QBUJFOUT VOEFSXFOU SBEJDBM SFTFDUJPO XIJMF
SFDFJWFE SFEVDUJPO TVSHFSZ 5IF VOJWBSJBUF TVSWJWBM BOBMZTJT TIPXFE UIBU QBUJFOUT XJUI TPMJUBSZ
DFSWJDBM OPEF SFMBQTF IBE B CFUUFS QSPHOPTJT UIBO QBUJFOUT XJUI NVMUJQMF OPEF SFMBQTF 1 1BUJFOUT XIP
XFSF EJBHOPTFE XJUI B SFDVSSFODF JO NPOUIT BGUFS FTPQIBHFDUPNZ IBE XPSTF PVUDPNFT UIBO QBUJFOUT XIP
SFMBQTFE NPOUIT MBUFS 1 1BUJFOUT XIP VOEFSXFOU SBEJDBM TBMWBHF MZNQIBEFOFDUPNZ IBE CFUUFS
TVSWJWBM UIBO QBUJFOUT XIP VOEFSXFOU SFEVDUJPO EJTTFDUJPO 1 5IF OVNCFS PG QPTJUJWF OPEFT BU
FTPQIBHFDUPNZ PS NPSF PS MFTT BOE TVSHJDBM USFBUNFOU GPS SFDVSSFODF SFEVDUJPO SBEJDBM TVSHFSZ XFSF
GPVOE UP IBWF JOEFQFOEFOU QSPHOPTUJD WBMVFT CZ NVMUJWBSJBUF BOBMZTJT XIFSFBT UIF PUIFS UXP GBDUPST XFSF OPU
TUBUJTUJDBMMZ TJHOJGJDBOU
MBK R MR 4BMWBHF DFSWJDBM MZNQIBEFOFDUPNZ QMVT BEKVWBOU SBEJPUIFSBQZ DIFNPUIFSBQZ JT BO
FGGFDUJWF BOE TBGF USFBUNFOU GPS &4 QBUJFOUT XIP EFWFMPQ DFSWJDBM MZNQI OPEF SFDVSSFODF BGUFS DVSBUJWF
FTPQIBHFDUPNZ MPXFS QSJNBSZ / TUBHF BOE SBEJDBM SFTFDUJPO PG SFDVSSFOU OPEFT XFSF GPVOE UP IBWF
JOEFQFOEFOU QSPHOPTUJD WBMVFT GPS UIFTF QBUJFOUT

CR &TPQIBHFBM OFPQMBTNT TBMWBHF MZNQIBEFOFDUPNZ MZNQI OPEF SFDVSSFODF

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BOE NJOJNBMMZ JOWBTJWF FTPQIBHFDUPNZ IBWF JNQSPWFE
UIF QSPHOPTJT BOE RVBMJUZ PG MJGF PG QBUJFOUT XJUI &4
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MPDPSFHJPOBM PS EJTUBOU SFDVSSFODF XJUIJO ZFBST BGUFS
FTPQIBHFDUPNZ
%JTUBOU SFDVSSFODFT DPNNPOMZ GPVOE JO UIF MVOHT
MJWFS BOE CPOFT BSF VTVBMMZ DPOTJEFSFE UP IBWF B TNBMM
DIBODF PG B DPNQMFUF DVSF BT OP FGGFDUJWF USFBUNFOU GPS TVDI
BEWBODFE EJTFBTFT JT DVSSFOUMZ BWBJMBCMF -PDPSFHJPOBM
SFDVSSFODFT JODMVEJOH SFDVSSFODFT BU UIF TJUF PG UIF QSJNBSZ
UVNPS PS MPDPSFHJPOBM MZNQI OPEFT BSF UIF NPTU GSFRVFOU
QBUUFSOT PG SFDVSSFODF BGUFS FTPQIBHFDUPNZ -ZNQI OPEF
SFDVSSFODFT JO UIF DFSWJDBM PS BU UIF DFMJBD USVOL SFHJPO
XFSF BMTP DPOTJEFSFE UP CF MPDPSFHJPOBM -ZNQI
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MZNQIBEFOFDUPNZ PNQBSFE XJUI SFDVSSFODF
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MZNQIBEFOFDUPNZ GPS DFSWJDBM OPEF SFDVSSFODF TFFNT UP
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UIFSBQZ TUSBUFHZ GPS JTPMBUFE SFDVSSFODF JO UIF DFSWJDBM
MZNQI OPEFT BGUFS DVSBUJWF SFTFDUJPO PG &4 IBT OPU CFFO
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O UIJT TUVEZ XF SFUSPTQFDUJWFMZ SFWJFXFE QBUJFOUT
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SBEJPUIFSBQZ DIFNPUIFSBQZ GPS SFDVSSFODF JTPMBUFE JO UIF
DFSWJDBM MZNQI OPEFT JO PVS DFOUFS 5IF BJN PG UIJT TUVEZ JT
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BO PQQPSUVOJUZ GPS DVSJOH QBUJFOUT XJUI JTPMBUFE DFSWJDBM
OPEF SFDVSSFODF BOE XIBU BSF UIF QSPHOPTUJD GBDUPST GPS UIF
QBUJFOUT BGUFS TBMWBHF USFBUNFOU
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UIF DFSWJDBM MZNQI OPEFT BOE VOEFSXFOU TBMWBHF DFSWJDBM
MZNQIBEFOFDUPNZ 8F FYDMVEFE QBUJFOUT XJUI DFSWJDBM
OPEF SFDVSSFODF QMVT PUIFS TJUFT PG SFDVSSFODF GSPN UIF
BOBMZTJT 1BUJFOUT XJUI DFSWJDBM OPEF JOWPMWFNFOU FYUFOEJOH
JOUP UIF NFEJBTUJOVN BOE QBUJFOUT XIP EJE OPU SFDFJWF
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3FWJFX PNNJUUFF PG VKJBO BODFS )PTQJUBM
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PUIFS IPNPMBUFSBM TVQSBDMBWJDVMBS OPEFT GUFS UIF TBMWBHF
TVSHFSZ QBUJFOUT XIP VOEFSXFOU SBEJDBM SFTFDUJPO PG UIF
SFDVSSFOU OPEFT XFSF USFBUFE XJUI r DPVSTFT PG BEKVWBOU
DIFNPUIFSBQZ VTJOH QMBUJOVN CBTFE UXP ESVH SFHJNFO
1PTUPQFSBUJWF DIFNPSBEJPUIFSBQZ XBT EFMJWFSFE UP UIF
TVQSBDMBWJDVMBS BOE VQ NFEJBTUJOBM MZNQIBUJDT XJUI B UPUBM
EPTF PG r (Z GPS QBUJFOUT XIP VOEFSXFOU SFEVDUJPO
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 PP N 6T P N V P N P N 0 ,WP 2

CF 1BUJFOU DIBSBDUFSJTUJDT BU UIF UJNF PG JOJUJBM FTPQIBHFDUPNZ GPS 8JOEPXT 0WFSBMM TVSWJWBM XBT EFGJOFE GSPN UIF
PG UIF QBUJFOUT XIP TIPXFE SFDVSSFODF BU DFSWJDBM OPEFT EBUF PG TBMWBHF MZNQIBEFOFDUPNZ UP UIF EBUF PG EFBUI
Characteristic n=66 PS GJOBM GPMMPX VQ 4VSWJWBM UJNF XBT EFSJWFE VTJOH UIF
Gender (%) ,BQMBO .FJFS NFUIPE BOE UIF EJGGFSFODFT CFUXFFO
DVSWFT XFSF BTTFTTFE CZ UIF MPH SBOL UFTU BDUPST XJUI
Male 54 (81.8)
statistical signi cance (P<0.05) in univariate analyses were
Female 12 (18.2) JOUSPEVDFE JOUP NVMUJWBSJBUF BOBMZTJT .VMUJWBSJBUF BOBMZTJT
Median age (years) 57 XBT QFSGPSNFE XJUI UIF PY QSPQPSUJPOBM IB BSE SFHSFTTJPO
Tumor location (%) NPEFM

Upper thoracic 12 (18.2)

Middle thoracic 41 (62.1) DR R

Lower thoracic 13 (19.7) C P C C C C

Esophagectomy procedure (%) 5IF DIBSBDUFSJTUJDT PG UIF QBUJFOUT BU UIF UJNF PG QSJPS
McKeown esophagectomy with 3FL 9 (13.6) FTPQIBHFDUPNZ BSF EFTDSJCFE JO CMF 5IF NBKPSJUZ PG
Mckeown esophagectomy with 2FL 44 (66.7) UIF QBUJFOUT XFSF NBMF BOE UIFJS NFEJBO BHF XBT
ZFBST /JOF PG UIF QBUJFOUT VOEFSXFOU .D,FPXO
Ivor-Lewis esophagectomy 7 (10.6)
FTPQIBHFDUPNZ XJUI UISFF GJFME MZNQIBEFOFDUPNZ
Sweet esophagectomy 6 (9.1) VOEFSXFOU .D,FPXO FTPQIBHFDUPNZ XJUI UXP
pTNM (%) GJFME MZNQIBEFOFDUPNZ VOEFSXFOU WPS -FXJT
I 2 (3.0)
FTPQIBHFDUPNZ BOE QBUJFOUT SFDFJWFE 4XFFU
FTPQIBHFDUPNZ 5IF GJFMET PG MZNQIBEFOFDUPNZ XFSF
II 29 (43.9)
EJDUBUFE NBJOMZ CZ UIF MPDBUJPO PG UVNPS UIF DMJOJDBM
III 35 (53.0) MZNQI OPEFT TUBUVT BT XFMM BT UIF TVSHFPOnT FYQFSJFODF
Number of positive nodes (%) BOE QSFGFSFODF PS MZNQI OPEFT QPTJUJWF QBUJFOUT UIF
BWFSBHF OVNCFS PG QPTJUJWF OPEFT XBT BOE GPS UXP
0 19 (28.8)
BOE UISFF GJFME MZNQIBEFOFDUPNZ SFTQFDUJWFMZ 1
1–2 27 (40.9)
5IF QSJNBSZ UVNPS MPDBUJPOT JODMVEFE UIF VQQFS
3–6 13 (19.7) NJEEMF BOE MPXFS
7 or more 7 (10.6) FTPQIBHVT 5IF QBUIPMPHJDBM TUBHFT XFSF TUBHF JO
3F L, three-f i el d l ymp ha denec to m y; 2F L, two -f i el d
TUBHF JO BOE TUBHF JO QBUJFOUT
lymphadenectomy. 5IFSF XFSF QBUIPMPHJDBMMZ OPEF OFHBUJWF
QBUJFOUT XJUI r QPTJUJWF OPEFT
XJUI r QPTJUJWF OPEFT BOE XJUI NPSF UIBO
QPTJUJWF OPEFT

GUFS TBMWBHF USFBUNFOU NPTU QBUJFOUT XFSF GPMMPXFE VQ JO

P C C P P F
the outpatient clinic every three months for the rst 2 years,
BOE FWFSZ NPOUIT UIFSFBGUFS PS QBUJFOUT XIP DPVME OPU 5IF DMJOJDBM GFBUVSFT PG UIF SFDVSSFOU OPEFT JO UIF
BGGPSE SFHVMBS GPMMPX VQ WJTJUT XF QFSGPSNFE UFMFQIPOF QBUJFOUT BSF TVNNBSJ FE JO CMF 5IF NFEJBO JOUFSWBM
GPMMPX VQ JOTUFBE 5IF NFEJBO GPMMPX VQ QFSJPE XBT GSPN UIF EBUF PG QSJPS TVSHFSZ UP UIF EBUF PG SFDVSSFODF
SBOHF r NPOUIT XBT SBOHF r NPOUIT NPOH BMM UIFTF QBUJFOUT
QBUJFOUT SFMBQTFE XJUIJO NPOUIT BGUFS
FTPQIBHFDUPNZ BOE SFDVSSFODFT XFSF GPVOE
C C CPC
NPOUIT MBUFS 4PMJUBSZ DFSWJDBM OPEF SFMBQTFT XFSF GPVOE JO
4UBUJTUJDBM BOBMZTJT XBT QFSGPSNFE VTJOH UIF 4UBUJTUJDBM QBUJFOUT XIJMF DBTFT TIPXFE NVMUJQMF
1BDLBHF GPS UIF 4PDJBM 4DJFODFT 4144 QSPHSBN WFSTJPO OPEFT SFMBQTFT JGUZ GPVS QBUJFOUT VOEFSXFOU

OOBMT PG 5SBOTMBUJPOBM .FEJDJOF MM SJHIUT SFTFSWFE S TM FE IUUQ EY EPJ PSH BUN

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SBEJDBM SFTFDUJPO BOE SFDFJWFE SFEVDUJPO P C C P C F C P F

TVSHFSZ O BEEJUJPO QBUJFOUT XFSF GPVOE UP IBWF P PF P C C CF P
TVQSBDMBWJDVMBS OPEFT SFDVSSFODF QBUJFOUT XFSF
6OJWBSJBUF BOBMZTJT XBT QFSGPSNFE GPS DMJOJDP QBUIPMPHJDBM
GPVOE UP IBWF DFSWJDBM QBSBUSBDIFBM OPEFT SFDVSSFODF BOE
GBDUPST SFMBUFE UP QSJPS TVSHFSZ BOE SFDVSSFOU OPEFT UP FYQMPSF
QBUJFOUT TIPXFE CPUI TVQSBDMBWJDVMBS BOE DFSWJDBM
GBDUPST BGGFDUJOH UIF QSPHOPTJT PG QBUJFOUT XIP IBE SFDVSSFODF
QBSBUSBDIFBM OPEFT SFDVSSFODF PVS NJOPS QPTUPQFSBUJWF
MJNJUFE UP UIF DFSWJDBM OPEFT NPOH UIF GBDUPST BOBMZTFE
DPNQMJDBUJPOT XFSF PCTFSWFE JODMVEJOH MZNQIPSSIFB BOE
UIF OVNCFS PG QPTJUJWF OPEFT BU FTPQIBHFDUPNZ PS NPSF
IPBSTFOFTT XIJDI XFSF NBOBHFE DPOTFSWBUJWFMZ 5IFSF XBT
PS MFTT UJNF UP SFDVSSFODF ≤ NPOUIT OVNCFS PG
OP QFSJPQFSBUJWF NPSUBMJUZ
SFDVSSFODF OPEFT NVMUJQMF TPMJUBSZ BOE TVSHJDBM USFBUNFOU
GPS SFDVSSFODF SFEVDUJPO SBEJDBM TVSHFSZ XFSF GPVOE UP
CF MJOJDBM DIBSBDUFSJTUJDT PG DFSWJDBM OPEFT SFDVSSFODF CF TJHOJGJDBOU QSPHOPTUJD GBDUPST CMF BOE SF
Characteristic n=66 0UIFS GBDUPST TVDI BT BHF HFOEFS UVNPS MPDBUJPO EFQUI
Time to recurrence (%) PG UVNPS JOWBTJPO BOE TJUF PG SFDVSSFODF EJE OPU BGGFDU UIF
QSPHOPTJT GUFSXBSET XF TVCKFDUFE UIF BCPWF GPVS GBDUPST
≤6 months 21 (31.8)
EFUFDUFE CZ VOJWBSJBUF BOBMZTJT UP NVMUJWBSJBUF BOBMZTJT
>6 months 45 (68.2) UP JEFOUJGZ JOEFQFOEFOU QSPHOPTUJD GBDUPST T TIPXO JO
Number of recurrence node (%) CMF UIF OVNCFS PG QPTJUJWF OPEFT BU FTPQIBHFDUPNZ
PS NPSF PS MFTT BOE TVSHJDBM USFBUNFOU GPS SFDVSSFODF
Solitary 31 (47.0)
SFEVDUJPO SBEJDBM TVSHFSZ XFSF GPVOE UP IBWF TJHOJGJDBOU
Multiple 35 (53.0)
QSPHOPTUJD WBMVFT XIFSFBT UIF PUIFS UXP GBDUPST XFSF OPU
Surgical treatment for recurrence statistically signi cant.
Radical surgery 54 (81.8)

Reduction surgery 12 (18.2) R RR M

Site of recurrence (%) .PSF UIBO PG QBUJFOUT XJUI &4 EFWFMPQFE B
Supraclavicular LNs 22 (33.3) SFDVSSFODF FWFO BGUFS DVSBUJWF FTPQIBHFDUPNZ XJUI
Cervical paratracheal LNs 39 (59.1) FYUFOEFE MZNQIBEFOFDUPNZ -PDPSFHJPOBM SFDVSSFODFT
JODMVEJOH MZNQI OPEF SFMBQTF BSF GSFRVFOUMZ PCTFSWFE BGUFS
Supraclavicular and cervical paratracheal LNs 5 (7.6)
FTPQIBHFDUPNZ .PSF UIBO PG QBUJFOUT IBWF CFFO

CF 6OJWBSJBUF BOBMZTJT PG QSPHOPTUJD GBDUPST GPS QBUJFOUT XJUI DFSWJDBM OPEF SFDVSSFODF UIBU VOEFSXFOU TBMWBHF MZNQIBEFOFDUPNZ
Factor P value

Age (more than 58/58 or younger) 0.58

Gender (male/female) 0.23

Tumor location (Ut/Mt + Lt) 0.18

Depth of tumor invasion at esophagectomy (T3-4/T1-2) 0.21

Number of positive nodes at esophagectomy (3 or more/2 or less) <0.001

Time to recurrence (>6/≤6 months) 0.007

Number of recurrence nodes (multiple/solitary) 0.001

Surgical treatment for recurrence (reduction/radical surgery) 0.004

Site of recurrence (supraclavicular/cervical paratracheal nodes) 0.49

Ut, upper thoracic; Mt, middle thoracic; Lt, lower thoracic.

OOBMT PG 5SBOTMBUJPOBM .FEJDJOF MM SJHIUT SFTFSWFE S TM FE IUUQ EY EPJ PSH BUN

 PP N 6T P N V P N P N 0 ,WP 2

1.0 1.0

0.8 0.8
2 or less positive nodes Recurrence 6
at esophagectomy (n=46) months later after
esophagectomy (n=45)
Survival rate

Survival rate
0.6 0.6

0.4 0.4 Recurrence in 6 months

after esophagectomy
(n=21)
3 or more positive nodes
0.2 at esophagectomy (n=20) 0.2

P<0.001 P=0.007
0.0 0.0
0.00 12.00 24.00 36.00 48.00 60.00 0.00 12.00 24.00 36.00 48.00 60.00
Months after salvage surgery Months after salvage surgery

1.0 1.0

0.8 0.8
Solitary recurrence node
(n=31)
Survival rate

Survival rate

0.6 0.6 Redical surgery (n=54)

0.4 Multiple recurrence nodes 0.4

(n=35)
Reduction surgery (n=12)
0.2 0.2

0.0 P=0.001 0.0 P=0.004

0.00 12.00 24.00 36.00 48.00 60.00 0.00 12.00 24.00 36.00 48.00 60.00
Months after salvage surgery Months after salvage surgery

VSF 6OJWBSJBUF BOBMZTJT PG QSPHOPTUJD GBDUPST GPS QBUJFOUT XJUI SFDVSSFODF JO UIF DFSWJDBM OPEFT 1BUJFOUT XJUI PS MFTT QPTJUJWF
nodes at esophagectomy had a better prognosis than those with 3 or more positive nodes at esophagectomy (P<0.001); (B) patients who were
EJBHOPTFE XJUI SFDVSSFODFT XJUIJO NPOUIT BGUFS FTPQIBHFDUPNZ IBE XPSTF PVUDPNFT UIBO QBUJFOUT XIP SFMBQTFE NPOUIT MBUFS 1
QBUJFOUT XJUI B TPMJUBSZ DFSWJDBM OPEF SFMBQTF IBE B CFUUFS QSPHOPTJT UIBO QBUJFOUT XJUI B NVMUJQMF OPEF SFMBQTF 1 % QBUJFOUT
XIP VOEFSXFOU SBEJDBM MZNQIBEFOFDUPNZ IBE CFUUFS TVSWJWBM UIBO QBUJFOUT XIP VOEFSXFOU SFEVDUJPO TVSHFSZ 1 5IF TUBUJTUJDBM
BOBMZTJT XBT DPOEVDUFE VTJOH B MPH SBOL UFTU

CF .VMUJWBSJBUF BOBMZTJT PG QSPHOPTUJD GBDUPST GPS QBUJFOUT XJUI DFSWJDBM OPEF SFDVSSFODF UIBU VOEFSXFOU TBMWBHF MZNQIBEFOFDUPNZ
Factor P value Exp value 95% CI

Number of positive nodes at esophagectomy (3 or more /2 or less) 0.004 3.020 1.415–6.444

Time to recurrence (>6/≤6 months) 0.133 0.580 0.285–1.181

Number of recurrence nodes (multiple/solitary) 0.113 1.895 0.859–4.183

Surgical treatment for recurrence (reduction/radical surgery) 0.001 3.928 1.743–8.852

SFQPSUFE UP EFWFMPQ DFSWJDBM MZNQI OPEF SFDVSSFODF BGUFS
DVSBUJWF SFTFDUJPO GPS UIPSBDJD &4 MUIPVHI
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ef cacy of salvage cervical node dissection has not yet been
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conduit. Thus, it is dif cult to compare outcomes in patients
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Con icts of Interest: The authors have no con icts of interest
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