Does the lymph node yield affect survival in patients with esophageal cancer receiving neoadjuvant therapy plus esophagectomy? A systematic review and updated meta-analysis

Abstract

Background Conflicting data have been reported on the prognostic impact of the extent of lymphadenectomy during esophagectomy for esophageal cancer (EC) after neoadjuvant therapy, especially after neoadjuvant chemoradiotherapy (nCRT). Methods A comprehensive online search was performed to explore the association between increased lymph node yield (LNY) and survival of patients with EC, in which the overall survival (OS) was set as the primary outcome. In addition to analysis of the entire cohort, subgroup analyses of different induction therapy and different populations were also performed. Findings A total of 19528 patients from twelve studies were included in our study. The pooled data revealed that more lymph node harvested was associated with better OS (HR = 0·87; 95% CI: 0·79–0·95, p < 0·001). Notably, a higher LNY was associated with better OS if the threshold was less than 18. However, more thorough lymphadenectomy might not bring additional survival benefits when it came to a cutoff value more than 18. The subgroup analysis further revealed that a higher LNY after nCRT was associated favorable survival. In terms of subset analysis of different populations, increased LNY was associated with longer OS in Western populations but not in Eastern. Interpretation Increased LNY during esophagectomy after neoadjuvant therapy, especially after nCRT, might be associated with improved OS. More studies are warranted to assess the survival benefits of a higher LNY receiving neoadjuvant therapy plus esophagectomy, especially in Eastern populations. Funding Supported by the projects from Suzhou Key Laboratory of Thoracic Oncology (SZS201907), Suzhou Key Discipline for Medicine (SZXK201803), the Science and Technology Research Foundation of Suzhou Municipality (SYS2018063, SYS2018064), Municipal Program of People's Livelihood Science and Technology in Suzhou (SS2019061) and Major Project for Social Development, Jiangsu Provincial Department of Science and Technology (SBE2020750085).

Textbook outcome for esophageal cancer surgery: an international consensus-based update of a quality measure

“… 17 The increase in minimum lymph node harvest required to achieve textbook outcome is in line with the increasing evidence that an extensive lymphadenectomy is associated with improved survival and optimized pathological staging, also after neo-adjuvant therapy, as shown in multiple recently published studies. 18–20 The median length of hospital stay decreased with the introduction of enhanced recovery programs and was 9 days for patients after an uncomplicated esophagectomy in the Netherlands, probably contributing to the decreased maximum hospital days to achieve textbook outcome. 21 , 22 Although these changes to the original textbook outcome seem to follow recent findings regarding esophageal cancer treatment in literature, no actual rationale for the inclusion of each of the items was provided by the responding surgeons.…”

Lymph node volume predicts survival in esophageal squamous cell carcinoma treated with neoadjuvant chemoradiotherapy and surgery

“…The median number of LN removed at surgery for the entire cohort and the 42 patients who experienced locoregional relapse as the first progression was 21.0 (IQR, 15.0–26.0) and 21.5 (IQR, 16.8–26.0), respectively. Based on the dissected LN number, lymphadenectomy appeared to be adequate in the present study [ 10 , 11 ]. Although CCRT induced regression of cancer cells in the LN, it might cause fibrosis of the nodes, making residual cancer cells adhere to the surrounding tissues, and leading to locoregional relapse.…”

Optimal Range of Lymphadenectomy in Pathological Stage T1 and T2 Esophageal Squamous Cell Carcinoma

“…Several previous studies have confirmed the association between the number of resected lymph nodes and the prognosis of ESCA (8)(9)(10). According to the current clinical guidelines, extensive lymphadenectomy can provide survival benefits and is hence considered the gold standard of treatment (11).…”