Impact of the number of resected lymph nodes on survival after preoperative radiotherapy for esophageal cancer

Impact of Dissected Lymph Node Count and Positive Lymph Node Ratio Following Esophagectomy on Long-Term Outcomes in Esophageal Cancer: A Systematic Review and Meta-Analysis

Objective

This meta-analysis evaluated how the number of lymph nodes dissected (LND) and the positive lymph node ratio (LNR) following esophagectomy influence long-term outcomes in esophageal cancer.

Background

Esophagectomy is a critical treatment for esophageal cancer, but the optimal extent of lymphadenectomy remains debated, especially in the era of modern neoadjuvant protocols.

Methods

A systematic electronic search of Embase, Medline, and the Cochrane Library was performed for studies published between 2000 and 2024. Included studies assess overall survival (OS) in patients with esophageal cancer undergoing esophagectomy with lymphadenectomy, comparing groups with high and low LND and LNR. A subset analysis examined outcomes in patients receiving neoadjuvant therapy.

Results

In total, 18 and 19 articles were included in the LND and LNR meta-analyses, respectively. High LND and low LNR were associated with improved OS [LND: hazard ratio (HR) = 0.75, 95% confidence interval (CI) = 0.67-0.85, P < 0.01; LNR: HR = 0.39, 95% CI = 0.33-0.47, P < 0.001]. Subset analysis revealed that these survival benefits persisted in patients who received neoadjuvant therapy (LND: HR = 0.56, 95% CI = 0.34-0.93, P = 0.01; LNR: HR = 0.24, 95% CI = 0.15-0.39, P < 0.001).

Conclusions

These findings highlight the prognostic importance of high LND and low LNR in improving OS following esophagectomy, regardless of neoadjuvant therapy. Extensive lymphadenectomy may enhance survival, and LNR provides a valuable prognostic tool for guiding postoperative treatment decisions.

Extended Lymphadenectomy Improves Survival After Induction Chemoradiation for Esophageal Cancer: A Propensity-Matched Analysis of the National Cancer Database

OBJECTIVES

The aim of this study was to explore the potential value of extended nodal-dissection following neoadjuvant chemoradiation (CRT), by analyzing data from the National Cancer Database (NCDB).

BACKGROUND

A CROSS-trial post-hoc analysis showed that the number of dissected lymph nodes was associated with improved survival in patients undergoing upfront surgery but not in those treated with neoadjuvant CRT.

METHODS

The NCDB was queried (2004-2014) for patients who underwent esophagectomy following induction CRT. Predictors of overall survival (OS) were assessed. The optimal number of dissected LNs associated with highest survival benefit was determined by multiple regression analyses and receiveroperating characteristic curve analysis. The whole cohort was divided into 2 groups based on the predefined cutoff number. The two groups were propensity-matched (PMs).

RESULTS

Esophagectomy following induction-CRT was performed in 14,503 patients. The number of resected nodes was associated with improved OS in the multivariable analysis (hazard ratio for every 10 nodes: 0.95 (95% confidence interval: 0.93-0.98). The cutoff number of resected LNs that was associated with the highest survival benefit was 20 nodes. In the PM groups, patients in the "≥20 LNs" group had a 14% relative-increase in OS ( P = 0.002), despite having more advanced pathological stages (stage II-IV: 76% vs 72%, P < 0.001), and higher number of positive nodes (0-2 vs 0-1, P < 0.001).

CONCLUSIONS

The total number of resected nodes is a significant determinant of improved survival following induction CRT in patients with either node negative or node positive disease. In the matched groups, patients with higher number of resected lymph nodes had higher OS rate, despite having more advanced pathological disease and higher number of resected positive lymph nodes.

Impacts of neoadjuvant therapy on the number of dissected lymph nodes in esophagogastric junction cancer patients

BACKGROUND

Neoadjuvant therapy favors the prognosis of various cancers, including esophagogastric junction cancer (EGC). However, the impacts of neoadjuvant therapy on the number of dissected lymph nodes (LNs) have not yet been evaluated in EGC.

METHODS

We selected EGC patients from the Surveillance, Epidemiology, and End Results (SEER) database (2006-2017). The optimal number of resected LNs was determined using X-tile software. Overall survival (OS) curves were plotted with the Kaplan-Meier method. Prognostic factors were evaluated using univariate and multivariate COX regression analyses.

RESULTS

Neoadjuvant radiotherapy significantly decreased the mean number of LN examination compared to the mean number of patients without neoadjuvant therapy (12.2 vs. 17.5, P = 0.003). The mean LN number of patients with neoadjuvant chemoradiotherapy was 16.3, which was also statistically lower than 17.5 (P = 0.001). In contrast, neoadjuvant chemotherapy caused a significant increase in the number of dissected LNs (21.0, P < 0.001). For patients with neoadjuvant chemotherapy, the optimal cutoff value was 19. Patients with > 19 LNs had a better prognosis than those with 1-19 LNs (P < 0.05). For patients with neoadjuvant chemoradiotherapy, the optimal cutoff value was 9. Patients with  > 9 LNs had a better prognosis than those with 1-9 LNs (P < 0.05).

CONCLUSIONS

Neoadjuvant radiotherapy and chemoradiotherapy decreased the number of dissected LNs, while neoadjuvant chemotherapy increased it in EGC patients. Hence, at least 10 LNs should be dissected for neoadjuvant chemoradiotherapy and 20 for neoadjuvant chemotherapy, which could be applied in clinical practice.

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

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).

Three-Field versus Two-Field Lymphadenectomy for Esophageal Squamous Cell Carcinoma: A Meta-analysis

BACKGROUND

Most surgeons now accept lymphadenectomy as an essential feature of the operative treatment of esophageal squamous cell carcinoma. Three-field and two-field lymphadenectomy are two of the most popular excision scopes among surgeons. Over recent years, researchers have performed a range of comparative studies regarding these techniques, although the conclusions remain inconsistent.

METHOD

We systematically retrieved the records of PubMed, Embase, The Cochrane Library, and ClinicalTrials.gov until October 2019 and performed preliminary and full-text screening of the articles. We used the NOS scale to evaluate the quality of the enrolled studies, with only medium- and high-quality studies included. Review Manager 5.3 and Stata15 were used for the meta-analysis.

RESULTS

A total of eight studies involving 1676 patients were included in the meta-analysis. The results showed that for esophageal squamous cell carcinoma using with two-field and three-field lymphadenectomy, although three-field lymphadenectomy led to the gaining of a higher number of lymph nodes, there were no significant differences between the two in terms of the number of positive lymph nodes and overall survival. Three-field lymphadenectomy also caused higher levels of intraoperative blood loss and higher morbidity of the anastomotic fistula. No significant differences in operation time, recurrent laryngeal nerve injury, pneumonia, chylothorax, anastomotic stenosis, ileus, cervical nodal recurrence and hospital mortality were observed.

CONCLUSIONS

According to our meta-analysis, two-field lymphadenectomy is recommended as a first-choice surgical treatment for esophageal squamous cell carcinoma. However, since the results showed a risk of bias, they should be treated with caution.

The Prognostic Value of the Number of Negative Lymph Nodes Combined with Positive Lymph Nodes in Esophageal Cancer Patients: A Propensity-Matched Analysis

BACKGROUND

Currently, the number of negative lymph nodes (NLNs) has been paid increasing attention and is considered a prognostic indicator in diverse cancers. Therefore, it is necessary to explore the association between number of NLNs and prognosis in esophageal cancer (EC) patients.

METHODS

Our data were obtained from the Surveillance, Epidemiology, and End Results 18 database. The X-tile plot was used to determine the optimal cut-off value of the number of NLNs, and propensity score matching (PSM) was performed according to the results of the X-tile plot.

RESULTS

A total of 4777 patients were eligible, and 882 pairs of patients were included after PSM. The result of the X-tile plot revealed an optimal cut-off value of three NLNs. Multivariate Cox regression analysis revealed better EC-specific survival (ECSS) in patients with more than three NLNs (hazard ratio [HR] 0.68, 95% confidence interval [CI] 0.59-0.77; p < 0.001) compared with patients with three or fewer NLNs. A subgroup analysis revealed better ECSS in patients with more than three NLNs with one to two (HR 0.57, 95% CI 0.46-0.71; p < 0.001) or three to six (HR 0.68, 95% CI 0.50-0.92; p = 0.012) positive lymph nodes (PLNs).

CONCLUSIONS

More than three NLNs is associated with better survival in EC patients, especially when the number of PLNs is one to two or three to six. We confirm that the combination of the number of NLNs and number of PLNs can provide better prognostic guidance for EC.

Resection of the irradiated esophagus: the impact of lymph node yield on survival

There is debate surrounding the appropriate threshold for lymph node harvest during esophagectomy in patients with esophageal cancer, specifically for those receiving preoperative radiation. The purpose of this study was to determine the impact of lymph node yield on survival in patients receiving preoperative chemoradiation for esophageal cancer. The National Cancer Database (NCDB) was utilized to identify patients with esophageal cancer that received preoperative radiation. The cohort was divided into patients undergoing minimal (<9) or extensive (≥9) lymph node yield. Demographic, operative, and postoperative outcomes were compared between the groups. Kaplan-Meier analysis with the log rank test was used to compare survival between the yield groups. Cox proportional hazards model was used to determine the association between lymph node yield and survival. In total, 886 cases were included: 349 (39%) belonging to the minimal node group and 537 (61%) to the extensive group. Unadjusted 5-year survival was similar between the minimal and extensive groups, respectively (37.3% vs. 38.8%; P > 0.05). After adjustment using Cox regression, extensive lymph node yield was associated with survival (hazard ratio 0.80, confidence interval 0.66-0.98, P = 0.03). This study suggests that extensive lymph node yield is advantageous for patients with esophageal cancer undergoing esophagectomy following induction therapy. This most likely reflects improved diagnosis and staging with extensive yield.

The Effect of Lymph Nodes' Histologic Response on Survival Outcomes in Moroccan Patients with Rectal Cancer

Prognosis for patients with locally advanced rectal cancer remains controversial. The purpose of this study was to elucidate possible association between therapeutic effect on lymph nodes (LNs) and patient prognosis. Overall, 149 patients with rectal cancer received preoperative radiotherapy in concomitance with chemotherapy or exclusive radiotherapy before rectal excision. Microscopic examination of formalin-fixed lymph nodes was assessed for therapeutic effect. The establishment of groups combined reaction tissue types of fibrosis, colloid, and necrosis after neoadjuvant treatment was assigned. The average age was 56.38 years, ranged between 22 and 88 years, 53% were female, and 47% were men, with a sex ratio of 1 : 12. In the present study, we noticed that after a median follow-up time of 40.67 months (0-83; SD: 21.1), overall survival was statistically significant depending on age groups. Kaplan-Meier analysis showed significant differences in the rate of patients with an age under 65 years (70.64%) versus those with an age over 85 years (36.5%) (p < 0.001). Also, the OS was statistically significant depending on therapeutic effect groups composed of 0TE (No Therapeutic effect), C+ (presence of only colloidal effect), F+ (presence of only fibrosis tissue), and ME+ (mixture of 2 or 3 types of therapeutic effect) group. Indeed, we observed a significantly higher OS rate in the ME + group (86%) compared with the OS rate of LNs group with no therapeutic effect (57%) (p=0.028). Additionally, there was a significant association between the presence of fibrosis on LNs and an extended delay of more than 8 weeks to neoadjuvant treatment completion and surgery. Our study indicates that the best patient prognosis could be predicted based on tumor presenting a best pathologic effect on lymph nodes, and that delaying surgery for more than 8 weeks to neoadjuvant treatment completion improves therapeutic response on LNs.

Pathological Tumor Regression Grade Classifications in Gastrointestinal Cancers: Role on Patients' Prognosis

Preoperative chemotherapy or combined radiotherapy and chemotherapy (CRT), followed by surgery, represents the standard approach for locally advanced esophageal, gastric, and rectal carcinomas. To adequately evaluate the effects of neoadjuvant CRT in the resection specimens, several histopathologic tumor regression grade (TRG) scoring systems have been introduced into clinical practice. The primary goal of these TRG systems relies on a correct prognostic stratification of patients in the attempt to help clinical decision-making and influence surgical strategies, postoperative adjuvant therapies, and surveillance intensity. However, most TRG systems suffer from poor reproducibility and low interobserver concordance rates. Many efforts have been made in the identification of alternative, robust, simple, and universally accepted TRG scoring systems, which would help in the comparison of different treatment strategies and in the standardization of multimodal therapies. The aim of this review is to analyze the most commonly used TRG systems in gastrointestinal cancers highlighting their pitfalls and usefulness, depending on the tumor type.

Prognostic Value of Lymph Node Yield on Overall Survival in Esophageal Cancer Patients: A Systematic Review and Meta-analysis

OBJECTIVE

This meta-analysis determines whether increased lymph node yield improves survival in patients with esophageal cancer undergoing esophagectomy with or without neoadjuvant therapy.

BACKGROUND

Esophagectomy involves resection of the esophagus and surrounding lymph nodes, which are commonly the first stations of cancer spread. The extent of lymphadenectomy during esophagectomy remains controversial, with several studies publishing conflicting results, especially in the era of neoadjuvant therapy.

METHODS

An electronic literature search was undertaken using Embase, Medline, and the Cochrane library databases (2000 to 2017). Articles with esophageal cancer patients undergoing esophagectomy with lymphadenectomy and investigating the effects of low and high lymph node yield on overall survival and disease-free survival were included. Meta-analysis of data was conducted using a random effects model. If the study divided the cohort into multiple groups based on lymph node yield, survival was compared between the lowest and highest lymph node yield groups. In addition to analysis of the entire cohort, subset analysis of only those patients receiving neoadjuvant therapy was also performed.

RESULTS

A total of 26 studies were included in this meta-analysis with a follow-up ranging from 15 to 94 months. For the analysis of overall survival, 23 studies were included. A meta-analysis showed that overall survival significantly improved in the high lymph node yield group [hazard ratio (HR) = 0.81; 95% confidence interval (95% CI) = 0.74-0.87; P < 0.01]. In the 10 studies describing disease-free survival, this was significantly improved in the high lymph node yield group (HR = 0.72; 95% CI = 0.62-0.84; P < 0.01). Subset analysis of neoadjuvant-treated patients demonstrated a survival benefit of high lymph node yield on overall survival (HR = 0.82; 95% CI = 0.73-0.92; P < 0.01).

CONCLUSION

This meta-analysis demonstrates the benefit of an increased lymph node yield from esophagectomy on overall and disease-free survival. In addition, a survival benefit of a high lymph node yield was demonstrated in patients receiving neoadjuvant therapy followed by esophagectomy.

Survival Impact of Total Resected Lymph Nodes in Esophageal Cancer Patients With and Without Neoadjuvant Chemoradiation

BACKGROUND

Current esophageal treatment guidelines suggest that, when more than 15 lymph nodes are detected, dissection should be done as the minimum requirement for staging in esophageal squamous cell carcinoma (ESCC) patients undergoing esophagectomy without induction chemoradiotherapy (CRT). However, for neoadjuvant CRT, there is limited information. We sought to clarify the role of lymphadenectomy in ESCC patients with and without neoadjuvant CRT.

PATIENTS AND METHODS

Data on 3156 ESCC patients receiving esophagectomy with (group 1, n = 1399) and without (group 2, n = 1757) neoadjuvant CRT between 2008 and 2014 were collected from a national cancer registry in Taiwan. The impact of the resected lymph nodes on overall survival was assessed according to pathologic stages. A Cox regression model was used to identify prognostic factors for overall survival.

RESULTS

Five-year overall survival rates were 35.6% for the entire group, 30.32% for group 1, and 39.55% for group 2 (p < 0.0001 for group 1 vs group 2). The best cutoff value was 21 lymph nodes in both group 1 and group 2. In group 1, the independent prognostic factors included age ≥ 54 years, clinical N status, y-pathologic T, y-pathologic N, y-pathologic stage, grade, location, margin status, esophagectomy (thoracoscopic vs open), and number of total resected lymph nodes (≤ 21 vs > 21). For group 2, the independent prognostic factors were gender, clinical stage, pathologic T, pathologic N, tumor length, grade, and margin status.

CONCLUSIONS

Extent of lymphadenectomy was associated with survival in patients with neoadjuvant CRT followed by esophagectomy. The optimum lymphadenectomy should be modulated by pathologic stage.

Neoadjuvant therapy in relation to lymphadenectomy and resection margins during surgery for oesophageal cancer

Differences in lymph node yield and tumour-involved resection margins comparing neoadjuvant therapy plus surgery with surgery alone for oesophageal cancer are unclear. Patients who underwent oesophageal cancer surgery in Sweden in 1987–2010 were included. Patients treated with neoadjuvant therapy were compared with those who underwent surgery alone. Outcomes were the number of examined lymph nodes (main outcome), number metastatic lymph nodes, and resection margin status. Rate ratios (RRs) and 95% CIs of lymph node yield were calculated by Poisson regression, and odds ratios (ORs) and 95% CIs of resection margin status by multivariable logistic regression, both adjusted for confounders. Among 1818 patients, 587 (32%) had received neoadjuvant therapy and 1231 (68%) had not. Lymph node yield was lower in the neoadjuvant therapy group (median 6 versus 8; adjusted RR 0.75, 0.73–0.78). Fewer metastatic nodes were identified following neoadjuvant therapy (median 0 versus 1; adjusted RR 0.76, 0.69–0.84). Neoadjuvant therapy associated to decreased risk of tumour-involved resection margins when adjusted for confounders except T-stage (OR 0.52, 0.38–0.70), but the association did not remain after adjustment for T-stage (OR 0.91, 0.64–1.29). Neoadjuvant therapy seems to decrease the lymph node yield and decrease the risk of tumour-involved resection margins by shrinking primary tumour.

Robot-Assisted Hybrid Esophagectomy Is Associated with a Shorter Length of Stay Compared to Conventional Transthoracic Esophagectomy: A Retrospective Study

Aim

To compare the peri- and postoperative data between a hybrid minimally invasive esophagectomy (HMIE) and the conventional Ivor Lewis esophagectomy.

Methods

Retrospective comparison of perioperative characteristics, postoperative complications, and survival between HMIE and Ivor Lewis esophagectomy.

Results

216 patients were included, with 160 procedures performed with the conventional and 56 with the HMIE approach. Lower perioperative blood loss was found in the HMIE group (600 ml versus 200 ml, p < 0.001). Also, a higher median number of lymph nodes were harvested in the HMIE group (median 28) than in the conventional group (median 23) (p = 0.002). The median length of stay was longer in the conventional group compared to the HMIE group (11.5 days versus 10.0 days, p = 0.03). Patients in the HMIE group experienced fewer grade 2 or higher complications than the conventional group (39% versus 57%, p = 0.03). The rate of all pulmonary (51% versus 43%, p = 0.32) and severe pulmonary complications (38% versus 18%, p = 0.23) was not statistically different between the groups.

Conclusions

The HMIE was associated with lower intraoperative blood loss, a higher lymph node harvest, and a shorter hospital stay. However, the inborn limitations with the retrospective design stress a need for prospective randomized studies. Registration number is DRKS00013023.