Distribution of lymph node metastases in esophageal adenocarcinoma after neoadjuvant chemoradiation therapy: a prospective study
verfasst von:
Eliza R. C. Hagens, Hannah T. Künzli, Anne-Sophie van Rijswijk, Sybren L. Meijer, R. Clinton D. Mijnals, Bas L. A. M. Weusten, E. Debby Geijsen, Hanneke W. M. van Laarhoven, Mark I. van Berge Henegouwen, Suzanne S. Gisbertz
The distribution of lymph node metastases in esophageal adenocarcinoma following neoadjuvant chemoradiation (nCRTx) is unclear, but may have consequences for radiotherapy and surgery. The aim of this study was to define the distribution of lymph node metastases and relation to the radiation field in patients following nCRTx and esophagectomy.
Methods
Between April 2014 and August 2015 esophageal adenocarcinoma patients undergoing transthoracic esophagectomy with 2-field lymphadenectomy following nCRTx were included in this prospective observational study. Lymph node stations according to AJCC 7 were separately investigated. The location of lymph node metastases in relation to the radiation field was determined. The primary endpoint was the distribution of lymph node metastases and relation to the radiation field, the secondary endpoints were high-risk stations and risk factors for lymph node metastases and relation to survival.
Results
Fifty consecutive patients were included. Lymph node metastases were found in 60% of patients and most frequently observed in paraesophageal (28%), left gastric artery (24%), and celiac trunk (18%) stations. Fifty-two percent had lymph node metastases within the radiation field. The incidence of lymph node metastases correlated significantly with ypT-stage (p = 0.002), cT-stage (p = 0.005), lymph angioinvasion (p = 0.004), and Mandard (p = 0.002). The number of lymph node metastases was associated with survival in univariable analysis (HR 1.12, 95% CI 1.068–1.173, p < 0.001).
Conclusions
Esophageal adenocarcinoma frequently metastasizes to both the mediastinal and abdominal lymph node stations. In this study, more than half of the patients had lymph node metastases within the radiation field. nCRTx is therefore not a reason to minimize lymphadenectomy in patients with esophageal adenocarcinoma.
Hinweise
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
In the Netherlands, patients with an esophageal adenocarcinoma are usually treated with neoadjuvant chemoradiotherapy (nCRTx) followed by a minimally invasive esophagectomy. In 2017, this were 88% and 98% of all operated esophageal cancer patients, respectively [1]. The number of lymph node metastases is the strongest prognostic parameter in both patients who are treated with and without nCRTx [2‐7]. In addition, in patients with an esophageal adenocarcinoma, the location of lymph node metastases may also be related to survival, as is the case in patients with squamous cell carcinoma [8, 9].
Since the introduction of nCRTx, the optimal extent of lymphadenectomy is an ongoing topic of discussion. nCRTx seems to affect both the number of resected lymph nodes and lymph node metastases and the distribution pattern of lymph node metastases [10‐12]. Evidence regarding the extensiveness of lymphadenectomy after nCRTx is conflicting, some authors find that the extend of lymphadenectomy is no longer associated with survival, while others describe a persisting relation between an extensive lymphadenectomy and a better prognosis [13‐15]. A few high-quality studies investigated the pattern of metastatic nodal dissemination in esophageal adenocarcinoma [11, 16, 17]. However, only one study focused on patients who received nCRTx [11].
Anzeige
If the distribution of lymph node metastases in patients with an esophageal adenocarcinoma after nCRTx is identified, the optimal surgical strategy for lymphadenectomy after nCRTx can be determined. The primary aim of this study was to define the distribution pattern of lymph node metastases in patients following nCRTx and minimally invasive esophagectomy. The secondary aims were to identify high-risk stations for lymph node metastases after nCRTx, to define the distribution of lymph node metastases in relation to the radiation field, to identify risk factors for lymph node metastases after nCRTx, and to determine the influence of the number of lymph node metastases on survival in patients with esophageal adenocarcinoma after nCRTx.
Methods
This prospective observational study was performed in the Amsterdam UMC, location AMC, The Netherlands. All consecutive patients with an esophageal adenocarcinoma scheduled for nCRTx and a minimally invasive esophagectomy between April 2014 and August 2015 were screened for eligibility. Analysis of lymph node metastases was based on histopathological evaluation of the resection specimen. According to national guidelines, this study was exempted from official institutional review board (IRB) approval. The STROBE guidelines were used to ensure the correct reporting of this observational study [18].
Patients
Consecutive patients with a histologically proven, resectable (cT0-1N + M0 and cT2-4aN1-3M0) esophageal carcinoma of the mid or distal esophagus (Siewert I), all treated with nCRTx followed by a thoracolaparoscopic esophagectomy with a two-field lymphadenectomy were included in this study. To keep the group homogeneous, only patients with an adenocarcinoma were included. Patients were excluded if surgical treatment consisted of a transhiatal esophagectomy.
Treatment algorithm
Preoperative staging was performed according to national guidelines [19]. In principle, an endoscopy with biopsies; an endoscopic ultrasound; a PET–CT scan of neck, thorax, and abdomen; and an ultrasound of the neck were to be performed. A suspected lymph node was defined as a node > 9 mm short axis or a node 5–9 mm short axis that is round, inhomogeneous, and has an irregular border (2 out of 3). If high paratracheal lymph node involvement (station 2) that would change the surgical plan from Ivor Lewis to McKeown was suspected on PET–CT, EBUS was performed to determine if they were positive. This lymph node station would be included in the radiation field and surgical resection if the lymph node was positive.
Anzeige
Treatment consisted of nCRTx (i.e. weekly carboplatin AUC 2 and paclitaxel 50 mg/m2 for 5 weeks combined with daily radiotherapy consisting of 23 fractions of 1.8 Gray: total of 41.4 Gray) followed by minimally invasive surgery [20, 21]. The clinical target volume was defined prior to neoadjuvant treatment as the gross tumor volume plus a margin for subclinical disease. The standard clinical target volume consisted of the gross tumor volume plus a margin of 3 cm in cranio-caudal direction. All clinical suspected lymph nodes were included in the radiation field.
The details of surgical treatment have been described elsewhere [22, 23]. In short, esophagectomy was performed by means of a thoracolaparoscopic approach with a two-field lymphadenectomy, formation of a gastric tube, and construction of an intrathoracic or cervical anastomosis depending on the location of the primary tumor and radiation field.
Standard lymphadenectomy consisted of the following lymph node stations (American Joint Committee on Cancer, AJCC, 7th edition esophageal cancer staging [24]): paratracheal lymph nodes (station 4R/L), lymph nodes in the aortopulmonary window (station 5), subcarinal lymph nodes (station 7), paraesophageal (station 8), and lymph nodes along the pulmonary ligament (station 9 R/L). If suspicious high paratreacheal lymph nodes were seen on preoperative imaging, station 2R and/or 2L were also resected. In the abdomen, the paracardial lymph nodes (station 16 R/L), the lymph nodes along the left gastric artery (station 17), common hepatic artery (station 18), splenic artery/hilum (station 19), lymph nodes around the celiac trunk (station 20), and in the hepatoduodenal ligament were collected. Each lymph node station was separately resected and stored in individual pathology containers. Lymph nodes in close proximity to the primary tumor were not separated from the esophagus in order not to damage the circumferential resection margin (CRM), but were marked with colored beads by the surgeon. This procedure enabled the same data extraction as for the lymph node stations that were resected separately.
After resection, the esophagectomy specimen was opened, embedded in paraffin and after fixation on formalin overnight, meticulously analyzed for remaining lymph nodes. Both remaining and separately resected lymph nodes were counted manually (during microscopic evaluation) and embedded in total in paraffin. No lymph node revealing solution was used. All lymph nodes under 5 mm were totally embedded for microscopic evaluation, larger lymph nodes were totally embedded in slices of 3–4 mm thick. Standard slides stained with hematoxylin and eosin were produced for histopathological microscopic analysis. In case of suspicion of micro-metastasis (0.2–2.0 mm) or isolated tumor cells in the lymph node, or in case of suspicion of residual tumor cells in patients with extensive response to neoadjuvant therapy, additional keratin (AE1/AE3) stains were performed.
For each lymph node station, the total number of lymph nodes was recorded, as well as the number of tumor-positive lymph nodes. Tumor stage was classified according to the TNM 7th edition staging system for esophageal cancer of the AJCC [24]. Tumor differentiation and histologic subtype were recorded, as well as presence of lymphovascular invasion, perineural growth, and the response of the primary tumor to nCRTx (Mandard tumor regression score, TRG) [25]. The resection margin of the esophagectomy specimen was considered tumor-positive (R1) if there was presence of tumor in the resection margin (proximal, distal, or CRM).
A radiation oncologist dedicated in the field of upper GI oncologic disease (DG) determined for each lymph node station individually whether it was located in- or outside the clinical target volume of the neoadjuvant radiation field. This analysis was performed postoperative: the radiation oncologist was blinded for the oncologic outcome in terms of presence and location of lymph node metastases. The lymph node station was scored as ‘outside of clinical target volume’ in case of partial coverage of a lymph node station.
Patients were clinically followed up until the 5th year postoperatively. Survival was defined as the time between surgery and death or the date of last follow-up. In October 2018, the status of all patients was recorded.
Outcome parameters
The primary outcome was the distribution pattern of lymph node metastases in patients following nCRTx and minimally invasive esophagectomy. The secondary outcomes were as follows: (1) high-risk stations for lymph node metastases after nCRTx, defined as lymph nodes stations in which lymph node metastases were observed in at least 15% of patients of the total cohort. This is an empirical cut-off value, based on a study which aimed to determine which node level should be included for radiotherapy by analyzing lymph node metastases rate in thoracic esophageal squamous cell carcinoma patients [26]; (2) The distribution of lymph node metastases in relation to the radiation field; (3) risk factors for developing lymph node metastases; and (4) long-term survival in relation to the number of lymph node metastases.
Anzeige
Statistical analysis
Data analysis was performed using SPSS statistical software package (version 25, SPSS Inc., Chicago, USA). For descriptive statistics, the mean (± SD) was used in case of a normal distribution of variables, and the median (interquartile range, IQR) was used for variables with a skewed distribution. Number of combinations of stations with positive lymph nodes were calculated manually. Univariate logistic regression was used to identify which factors were associated with the prevalence of lymph node metastases. Based on literature, the following variables were tested whether or not they were correlated with the presence of lymph node metestases: ypT-stage; cT-stage; TRG; the number of resected lymph nodes; tumor differentiation; and downstaging of the primary tumor [27, 28]. Cox logistic regression modeling was used to assess the relationship between number of lymph node metastases with overall survival, providing hazard ratios (HRs) with 95% confidence intervals (CIs). Patients with missing data were excluded for analysis. A p value of < 0.05 was considered to be statistically significant. No multivariable analysis with adjustment for potential confounding factors could be performed due to the small number of events.
Results
Patients
Between April 3, 2014 and August 8, 2015, 112 consecutive patients underwent an esophagectomy. Sixty-two of 112 patients were excluded because of various reasons (Fig. 1). Characteristics of the 50 included patients are shown in Table 1. All patients completed the neoadjuvant nCRTx. Surgery was performed a median of 69 (IQR 56–82) days after nCRTx. All patients were operated by a minimally invasive approach (both 3-stage and 2-stage procedures), and no conversions were necessary. In all patients, a 2-field lymphadenectomy was performed as planned. Results and characteristics of the surgical intervention are shown in Table 2.
IQR interquartile range, EUS endoscopic ultrasound; CROSS-scheme: neoadjuvant chemoradiation therapy consisting of weekly infusions of carboplatin and paclitaxel (total 5 weeks) combined with daily radiotherapy (23 fractions of 1.8 Gray: total of 41.4 Gray). TRAP-scheme consisted of the CROSS-scheme, with the addition of with trastuzumab and pertuzumab as part of a clinical trial
Table 2
Operative and postoperative parameters
n (%)
Anastomosis
Cervical left
14 (28)
Cervical right
3 (6)
Intrathoracic
33 (66)
Number of examined lymph nodes, median (IQR)
37 (26–43)
Number of tumor-positive lymph nodes of patients with LNM, median (IQR)
A total of 1802 lymph nodes were removed in 50 patients with a median of 37 (IQR 26–43) lymph nodes per patient. In 30/50 (60%) patients, tumor-positive lymph nodes were detected with a median of 3 (IQR 1–8) tumor-positive lymph nodes per patient.
Number of lymph nodes removed per lymph node station
The number of lymph nodes removed per lymph node station is displayed in Table 3. Overall, most lymph nodes were removed from the subcarinal and paraesophageal lymph node stations and the least lymph nodes were removed at the level of the left side of trachea and pulmonary ligament (Table 3).
Table 3
Location of LNM in patients with an esophageal adenocarcinoma
The location of the lymph node metastases is shown in Table 3 and Fig. 2. Lymph node metastases were observed most frequently in the paraesophageal lymph nodes (n = 14, 28%) and in the lymph nodes along the left gastric artery (n = 12, 24%). In 13/30 (43%) patients, lymph node metastases were found both in the mediastinum and in the abdomen. Seven out of thirty patients (23%) had lymph node metastases in the mediastinum only, while 10/30 (33%) had lymph node metastases in the upper abdomen only. Within the 30 patients with lymph node metastases, 26 unique combinations of metastatic lymph node stations were seen. No specific distribution pattern could therefore be identified. However, analysis of the high-risk echelons showed that 20% (6/30) of patients had lymph node metastases both in celiac trunk lymph nodes as well as in the left gastric artery nodes. In 17%, (5/30) of the cases, lymph node metastases were found in both the right paracardial lymph nodes and in the lymph nodes along the celiac trunk. Lymph node metastases along the left gastric artery and metastases in the high paratracheal lymph nodes were another frequent combination, which was found in 13% (4/30) of cases.
Fig. 2
Incidence lymph node metastases per lymph node station in patients with an esophageal adenocarcinoma
×
High-risk zones for lymph node metastases
With a cut-off value of 15%, the following lymph node stations were considered as high-risk echelons: paraesophageal lymph nodes (28%), left gastric artery lymph nodes (24%), celiac trunk lymph nodes (18%), and the left paracardial lymph nodes (16%).
Location of lymph node metastases in relation to the radiation field
Fifty-two percent of the patients in this study had lymph node metastases within the radiation field. Out of all patients with lymph node metastases, 37% had lymph node metastasis within the radiation field alone. Thirteen percent of patients had lymph node metastasis solely outside of the radiation field, and 50% of the patients had lymph node metastases both within and outside of the radiation field. Together these patients had a median of 1 (range 0–6) lymph node station containing positive lymph nodes within the radiation field. When summing all lymph node stations with metastatic lymph nodes, 51 out of 80 (64%) lymph node stations were found outside the radiation field (Table 3).
In the 30 patients with lymph node metastases, a total of 228 tumor-positive lymph nodes were excised. 177/228 lymph nodes were separately removed and 51 lymph nodes were attached to the esophagectomy specimen. Fifty-four percent (121/228) of the positive lymph nodes were located within the radiation field. Of all lymph node metastases in high-risk stations, 74% was located in the radiation field.
Anzeige
Risk factors for lymph node metastases
The incidence of lymph node metastases in patients with an esophageal adenocarcinoma correlated with the tumor invasion depth in univariable analyses; ypT-stage (p = 0.002). Lymph node metastases were found in 83%, 67%, and 27% of patients with an ypT3, ypT2, and ypT1 tumor, respectively. Other factors associated with the presence of lymph node metastases in univariable analyses were cT-stage (71% vs. 25% of the patients with a cT3 vs. cT2 tumor had lymph node metastases, p = 0.005) and lymph angioinvasion (87% with lymph angioinvasion vs. 52% without lymph angioinvasion had lymph node metastases, p = 0.004). Seventeen percent (1 out of 6) with a complete response (TRG 1), 64% (27 patients out of 42) of patients with a partial response (TRG 2–4), and 100% (2 patients) of patients with no response had lymph node metastases (p = 0.002, univariable analyses). The number of resected lymph nodes, tumor differentiation, and downstaging of the primary tumor were not associated with the presence of lymph node metastases (p = 0.086, p = 0.882 and p = 0.076, respectively).
Long-term survival
The median follow-up of all patients was 26.8 months (range 1.6–50.3). The 1-, 2-, and 3-year overall survival (OS) rates were 76%, 54%, and, 30%, respectively, and the median survival was 28.9 months. The number of lymph node metastases was significantly associated with survival in univariable analysis (HR 1.12, 95% CI 1.07–1.17, p < 0.001). Figure 3 shows survival curves for patients with 0, 1, 2–4, or 5 ≤ positive lymph nodes.
Fig. 3
Long-term survival in patients with an esophageal adenocarcinoma with 0, 1, 2–4, or 5 ≤ positive lymph nodes
×
Discussion
The aim of the present study was to identify the distribution pattern of lymph node metastases after nCRTx and minimally invasive esophagectomy in patients with a resectable esophageal adenocarcinoma. No specific pattern of lymphatic spread could be identified, although a few lymph node stations were associated with an increased risk for lymph node metastases after nCRTx. High-risk lymph node stations included the paraesophageal, left gastric artery, celiac trunk, and the left paracardial lymph node stations. Furthermore, a high incidence of lymph node metastases (53%) was found within the radiation field. Minimally invasive surgery was conducted in all patients; no conversions were necessary and an adequate lymphadenectomy was possible in all these neoadjuvantly treated patients.
One other study investigated the location of metastatic nodes with regard to the neoadjuvant radiation field and assessed survival in esophageal cancer patients who were complete responders to nCRTx [29]. They found that 11 patients (21%) had positive lymph nodes in their cohort, of which 8 patients had lymph node metastases outside of the radiation field. Interestingly, the most frequent locations with lymph node metastases were the paraesophageal lymph nodes, lymph nodes along the gastric artery and pericardial lymph nodes, similarly as we found in the present study.
Seven patients (23%) showed lymph node metastases in the right upper paratracheal lymph nodes (station 2R), even though all these patients had distal esophageal tumors. Four of these seven patients did not have lymph node metastases in the lower paratracheal or subcarinal lymph node stations. Lymph node metastases in these intermediate lymph node stations could have been eradicated by the nCRTx, but these findings can also be explained by the phenomenon called skip metastases. Some studies reported on the occurrence of skip metastases in patients with an esophageal adenocarcinoma and to a greater extent in patients with an esophageal squamous cell carcinoma, with an incidence of up to 60% [16, 30‐32]. Skip metastases are thought to occur as a consequence of the extensive network of submucosal lymphatic vessels, which extend both longitudinally in a cranial and caudal direction and laterally, draining in the thoracic duct [32‐35]. Skip metastasis is a common form of lymphatic spread in esophageal cancer, which is associated with a favorable prognosis [36].
Fifty-two percent of all patients treated with nCRTx had tumor-positive lymph nodes located within the radiation field. Despite optimal radiotherapy in this area, these lymph node stations were not sterilized of tumor cells. A recent study by Talsma et al. questioned the indication for maximization of lymphadenectomy after nCRTx. This study was based on the data of the CROSS trial, which compared nCRTx plus surgery with surgery alone for patients with esophageal cancer [1, 2]. Talsma et al. found a positive correlation between the number of resected nodes and the number of resected positive nodes, which was significant in the surgery-alone group but not in the nCRTx plus surgery group. The authors explained this phenomenon by the possibility that positive locoregional lymph nodes are sterilized by nCRTx, which is in contrast to our findings. Talsma et al. found lymph node metastases in 32% of patients, compared to 60% in our cohort. Additionally, the median number of resected lymph nodes was only 14, compared to 36 in our study. A possible explanation is that in Talsma’s study, patients were under staged due to a less adequate lymphadenectomy. Surgery was not standardized in the CROSS trial, and there was no surgical quality control system, while in this cohort all patients underwent the same surgical procedure [20].
High-risk lymph node stations included both stations below and above the diaphragm. This is troublesome since patients who had lymph node metastases on both sides of the diaphragm have a significantly worse OS than those who had lymph node metastases only above or only below the diaphragm [12, 37]. The present study showed that that the number of lymph node metastases is strongly associated with survival, as is in accordance with literature [2‐7]. Lagarde et al. and Anderegg et al. reported that the presence of lymph node metastases in the proximal field of the chest and near the celiac trunk are both associated with impaired survival, and the survival significantly worsened with lymph node metastases in both areas [38, 39]. The question remains whether it is the number of lymph node metastases or the location of the lymph node metastases which influences survival. The relationship between location of lymph node metastases and survival could not be analyzed in this study because of the small sample size.
It must be pointed out that a lymph node station was considered high risk if at least 15% of the patients had lymph node metastases in this station. This cut-off is based on a study in esophageal cancer patients, which might have a different metastasizing pattern and therefore this might have influenced the results. Mandard score, cT-stage, lymphovascular invasion, and ypT-stage were significantly associated with the occurrence of lymph node metastases. Due to the small sample size, no multivariate analysis was performed. Other factors also reported to be associated with the presence of lymph node metastases are tumor location and tumor differentiation; however, this was not observed in this study. The association with the difference in tumor location could not be studied in this study since we only included 3 patients with a mid-esophageal tumor and 47 with a distal esophageal tumor [40, 41].
A few limitations of this study have to be acknowledged. Since all included patients were operated in a tertiary care center for esophageal cancer care, patient selection bias could have influenced the results. Another limitation is the small number of patients in this study. Analyses of long-term survival in relation to the number of lymph node metastases and risk factors for developing lymph node metastases were not corrected for possible confounding factors since a larger cohort is needed for a multivariate survival analysis.
It was also challenging to determine where the borders of a lymph node station are located anatomically and to correlate this to the exact location on the CT scan (when determining the relation between localization of lymph node metastases and the clinical target volume), specifically for the lymph node stations around the branches of the celiac trunk. Moreover, no 4D-CT scan in treatment positioning was performed at the time, which is part of the routine nowadays. 4D-CT scans enable treatment positioning to be more specific as it captures the location and movement of the body over time. This solves the issue with the conventional CT scan where part of the target area might be outside the radiation field because of the mobility caused by breathing. This is especially the case for distal and junction esophageal tumors because of the mobility in this region [42].
The discordance of the anatomical borders of the lymph node stations in relation to the radiation field is already remarkable within the use of one lymph node classification, let alone when it comes to defining the locations of lymph nodes within various classifications, such as the Japanese Esophageal Society (JES) and the AJCC, which are the most used tools in esophageal lymph node mapping. Therefore, uniform and clear definitions for the extent of each lymph node station should be defined and used worldwide.
It should be noted that neoadjuvant chemoradiotherapy might have influenced the lymph node distribution pattern and therefore our results do not represent distribution of lymph node metastases in untreated disease. However, many patients with an esophageal adenocarcinoma are today treated with neoadjuvant chemoradiotherapy prior to (minimally invasive) surgery. Results from this study are therefore more relevant to the current clinical practice with regard to the necessary extent of the lymphadenectomy. Moreover, a substantial part of the lymph node metastases in this cohort was found inside the radiation field, indicating that radiotherapy does not sterilize all lymph node metastases. Therefore, after neoadjuvant therapy, surgery remains of utmost importance. Complete lymphadenectomy might help to improve patients’ prognosis.
In order to be able to determine the true distribution of lymph node metastases in esophageal carcinoma and its impact on long-term survival, a large prospective study should be performed using a uniform classification system and discriminating between potential confounders such as different histological types of esophageal carcinoma, locations of the tumor, (neo)adjuvant treatment regimens and tumor stage. An initiative for such a study is the currently recruiting international TIGER study (NCT03222895). With the results of this study, the optimal radiation field and surgical strategy can more reliably be determined.
In conclusion, esophageal adenocarcinoma frequently metastasizes to both the mediastinal and abdominal lymph node stations. Of all patients treated with nCRTx and minimally invasive surgery, 52% had lymph node metastases within the radiation field. nCRTx is therefore not a reason to minimize lymphadenectomy in patients with esophageal adenocarcinoma. Moreover, a higher ypT-stage, cT-stage, Mandard score, and the presence of lymph angioinvasion are associated with a higher incidence of lymph node metastases and in univariable analysis a higher number of lymph node metastases is associated with a worse survival.
Compliance with ethical standards
Disclosure
Drs Hagens, Künzli, van Rijswijk, Meijer, Mijnals, Geijsen, and Gisbertz have no conflicts of interest of financial ties to disclose. van Berge Henegouwen has served as consultant for Medtronic and has received unrestricted research funding from Olympus and Stryker. Hanneke W. M. van Laarhoven has served as a consultant for BMS, Celgene, Lilly, and Nordic and has received unrestricted research funding from Bayer, Celgene, Lilly, Merck Serono, MSD, Nordic, Philips, and Roche. Bas Weusten received research support for IRB approved studies from GI Solutions Covidien, Erbe, and C2 Therapeutics. He received a honorarium consultancy speakers fee of Boston Scientific and C2Therapeutics.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Mit der Zeitschrift Die Chirurgie erhalten Sie zusätzlich Online-Zugriff auf weitere 43 chirurgische Fachzeitschriften, CME-Fortbildungen, Webinare, Vorbereitungskursen zur Facharztprüfung und die digitale Enzyklopädie e.Medpedia.
Bis 30. April 2024 bestellen und im ersten Jahr nur 199 € zahlen!
Distribution of lymph node metastases in esophageal adenocarcinoma after neoadjuvant chemoradiation therapy: a prospective study
verfasst von
Eliza R. C. Hagens Hannah T. Künzli Anne-Sophie van Rijswijk Sybren L. Meijer R. Clinton D. Mijnals Bas L. A. M. Weusten E. Debby Geijsen Hanneke W. M. van Laarhoven Mark I. van Berge Henegouwen Suzanne S. Gisbertz
Prof. Dr. med. Gregor Antoniadis Das Karpaltunnelsyndrom ist die häufigste Kompressionsneuropathie peripherer Nerven. Obwohl die Anamnese mit dem nächtlichen Einschlafen der Hand (Brachialgia parästhetica nocturna) sehr typisch ist, ist eine klinisch-neurologische Untersuchung und Elektroneurografie in manchen Fällen auch eine Neurosonografie erforderlich. Im Anfangsstadium sind konservative Maßnahmen (Handgelenksschiene, Ergotherapie) empfehlenswert. Bei nicht Ansprechen der konservativen Therapie oder Auftreten von neurologischen Ausfällen ist eine Dekompression des N. medianus am Karpaltunnel indiziert.
Dr. med. Benjamin Meyknecht, PD Dr. med. Oliver Pieske Das Webinar S2e-Leitlinie „Distale Radiusfraktur“ beschäftigt sich mit Fragen und Antworten zu Diagnostik und Klassifikation sowie Möglichkeiten des Ausschlusses von Zusatzverletzungen. Die Referenten erläutern, welche Frakturen konservativ behandelt werden können und wie. Das Webinar beantwortet die Frage nach aktuellen operativen Therapiekonzepten: Welcher Zugang, welches Osteosynthesematerial? Auf was muss bei der Nachbehandlung der distalen Radiusfraktur geachtet werden?
Dr. med. Mihailo Andric Inhalte des Webinars zur S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“ sind die Darstellung des Projektes und des Erstellungswegs zur S1-Leitlinie, die Erläuterung der klinischen Relevanz der Klassifikation EAES 2015, die wissenschaftliche Begründung der wichtigsten Empfehlungen und die Darstellung stadiengerechter Therapieoptionen.
