Lymphadenectomy after neoadjuvant chemoradiation for esophageal adenocarcinoma: what is the optimal lymph nodes dissection?

Abstract Background The optimal lymph nodes dissection (LND) for esophageal adenocarcinoma (EAC) patients who underwent neoadjuvant chemoradiotherapy (NCRT) is controversial. Methods Patients were selected from Surveillance Epidemiology and End Results database. Multivariable Cox analysis was used to identify predictors of overall survival (OS). Restricted Cubic Splines (RCS) was used to examine the relationship between the number of LND and OS. Result 2,019 patients with non-metastatic EAC underwent NCRT were stratified into three groups according to LND using X-tile software: group 1: 1–8, group 2: 9–14, group 3: ≥15. In Multivariable Cox Regression analysis, the death risk was reduced by 22% (P = 0.001), 43% (P < 0.001) respectively, for patients in groups 2, 3 compared with those in group 1. The results were similar for patients with pathological lymph node-negative (ypN0) EAC patients. But for pathological lymph node-positive (ypN+) patients, a significantly reduced hazard was present only in group 3 (P < 0.001). RCS exhibited a nonlinear relationship between the number of lymph nodes removed and OS for ypN0 EAC (P = 0.002). The risk of death sharply dropped until around 24 nodes removed and then started to steadily increase afterward. However, for ypN + EAC, it showed a linear relationship between LND and OS (P = 0.205), with a better OS when an increase in the number of lymph nodes removed. Conclusions For ypN0 patients, the optimal LND was approximately 24 lymph nodes, with the number of lymph nodes removed beyond 24 nodes did not provide additional benefit. However, for ypN + patients, a more extensive lymphadenectomy could favor survival.