Extent of lymphadenectomy in thoracic esophageal squamous cell carcinoma: a meta-analysis of three-field versus...

The comparative oncologic and perioperative benefits of three-field versus two-field lymphadenectomy in thoracic esophageal squamous cell carcinoma (ESCC) remain debated. This systematic review and meta-analysis evaluated outcomes across survival, nodal clearance, surgical metrics, and postoperative complications.

A systematic search of PubMed, Scopus, and Web of Science was conducted up to June 15th, 2025. Comparative studies reporting outcomes of 3-field (3FL) versus 2-field (2FL) lymphadenectomy in thoracic ESCC were included. Primary outcomes were overall survival (OS), disease-free survival (DFS), recurrence, residual tumor status, and nodal/metastatic involvement. Secondary outcomes included lymph node yield, operative time, blood loss, hospital stay, complications, and mortality. Random-effects meta-analyses were performed using odds ratios (ORs) or mean differences (MDs) with 95% confidence intervals (CIs).

Twenty-seven studies (28 reports) involving 10,039 patients (3FL: 3,389; 2-field: 6,504) were included. No significant differences were found in OS or DFS across all timepoints. R0 resection and recurrence rates were comparable. Three-field lymphadenectomy was associated with a higher number of dissected lymph nodes (MD = 15.01; 95% CI: 7.74-22.28), although heterogeneity was very high and small-study effects were detected. N + rates were only marginally higher with 3FL and did not reach significance (OR = 1.20; 95% CI: 0.99-1.47). Operative time, blood loss, and hospital stay were similar overall, but sensitivity analyses showed longer operative time and greater blood loss with the 3-field technique. Overall complication rates were not significantly different between groups; however, pulmonary complications (OR = 1.67; 95% CI: 1.06-2.63) and recurrent laryngeal nerve palsy (OR = 1.69; 95% CI: 1.06-2.69) were significantly higher with 3FL. Mortality rates were largely comparable, though in-hospital mortality was lower in the 3FL group (OR = 0.35; 95% CI: 0.13-0.93).

Three-field lymphadenectomy in thoracic ESCC provides superior nodal clearance but does not improve long-term survival compared to the two-field approach. It is associated with increased risk of certain complications. These findings highlight the trade-off between oncologic radicality and surgical risk, underscoring the need for individualized surgical decision-making.