Therapeutic value of lymphadenectomy after neoadjuvant chemotherapy in esophageal squamous cell carcinoma

Esophageal squamous cell carcinoma (ESCC) is characterized by a high incidence of lymph node metastasis, and prophylactic lymphadenectomy plays a critical role in esophagectomy. However, the optimal extent of lymphadenectomy after neoadjuvant chemotherapy (NAC) remains unclear. We aimed to investigate the extent and significance of lymphadenectomy after NAC by comparing its therapeutic impact with that of upfront esophagectomy.

In total, 200 consecutive patients who underwent McKeown esophagectomy for ESCC between 2009 and 2021 were eligible. We compared the therapeutic value index (TVI) between patients who underwent esophagectomy after NAC and those who underwent upfront esophagectomy.

96 (48.0%) patients underwent upfront esophagectomy and 104 (52.0%) patients underwent esophagectomy after NAC. In the upper mediastinum, middle/lower mediastinum, and peri-gastric regions, TVI in the NAC group was greater than that in the upfront group. In contrast, subcarinal lymphadenectomy showed no therapeutic benefit in the NAC group, and supra-pancreatic TVI was lower in the NAC group than in the upfront group (2.4 vs. 7.0). After propensity score matching (PSM), the results were essentially unchanged from those before matching. Subgroup analysis revealed almost no therapeutic benefit in the supra-pancreatic region for upper/middle thoracic tumors or early-stage cancers, whereas a benefit remained for lower thoracic tumors.

Lymphadenectomy in the upper mediastinum, middle/lower mediastinum, and peri-gastric regions remains important after NAC for ESCC. However, the apparent therapeutic value of subcarinal and supra-pancreatic lymphadenectomy was limited after NAC.