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From the Second Department of Surgery (MT, HK, NN) and Department of Central Pathological Laboratory (MR), Shimane Medical University, Izumo, Japan; Department of Medical Information Science (NK), Faculty of Medicine, Kyushu University, Fukuoka-shi, Japan; and Department of Surgery (AGL), University of Nevada, School of Medicine, Las Vegas, Nevada.
Correspondence: Address correspondence and reprint requests to: Dipok Kumar Dhar, MD, Second Department of Surgery, Shimane Medical University, Izumo 693-8501, Japan; Fax: 81-853-202229; E-mail: nigeka33{at}shimane-med.ac.jp
Background: The prognosis of patients with esophageal cancer remains dismal, and their care poses a great challenge of customizing therapeutic strategies for individual patients. Lymph node staging is still less than ideal in esophageal cancer patients. Therefore, we investigated a new approach to lymph node analysis.
Methods: One hundred eighty-seven patients curatively resected for squamous cell cancer of the esophagus were studied. The long diameter of the largest metastatic lymph node (MLN) was measured on a histopathologic slide and was considered as the MLN size.
Results: Patient survival decreased with each millimeter increment in MLN size. By using MLN size as the lymph node classification criterion, patients with MLN <10 mm had both a significantly better overall and cancer-specific survival than those with MLN 
10 mm. Patients with fewer than four MLNs were separated into prognostic groups according to the MLN size. Among the several prognostic factors, MLN size remained the strongest independent predictor of survival by multivariate analysis. This nodal analysis allowed stratification of patients into four stages with distinctly different survivals.
Conclusions: This approach supplements traditional nodal staging strategies and therefore has potential for guiding the development of treatment strategies in this carcinoma.
Key Words: Esophageal carcinoma • Staging • Prognosis • Metastatic lymph node size • Metastatic lymph node number
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