• Smita Sihag, Tamar Nobel, Meier Hsu, Kay See Tan, Rebecca Carr, Yelena Y Janjigian, Laura H Tang, Abraham J Wu, Matthew J Bott, James M Isbell, Manjit S Bains, David R Jones, and Daniela Molena.
• Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
• Ann. Surg. 2022 Aug 1; 276 (2): 312317312-317.

ObjectiveWe sought to determine the extent of lymphadenectomy that optimizes staging and survival in patients with locally advanced EAC treated with neoadjuvant chemoradiotherapy followed by esophagectomy.Summary Of Background DataSeveral studies have found that a more extensive lymphadenectomy leads to better disease-specific survival in patients treated with surgery alone. Few studies, however, have investigated whether this association exists for patients treated with neoadjuvant chemoradiotherapy.MethodsWe examined our prospective database and identified patients with EAC treated with neoadjuvant chemoradiotherapy followed by esophagectomy between 1995 and 2017. Overall survival (OS) and DFS were estimated using Kaplan-Meier methods, and a multivariable Cox proportional hazards model was used to identify independent predictors of OS and DFS. The relationship between the total number of nodes removed and 5-year OS or DFS was plotted using restricted cubic spline functions.ResultsIn total, 778 patients met the inclusion criteria. The median number of excised nodes was 21 (interquartile range, 16-27). A lower number of excised lymph nodes was independently associated with worse OS and DFS (OS: hazard ratio, 0.98; confidence interval, 0.97-1.00; P = 0.013; DFS: hazard ratio, 0.99; confidence interval, 0.98-1.00; P = 0.028). Removing 25 to 30 lymph nodes was associated with a 10% risk of missing a positive lymph node. Both OS and DFS improved with up to 20 to 25 lymph nodes removed, regardless of treatment response.ConclusionsThe optimal extent of lymphadenectomy to enhance both staging and survival after chemoradiotherapy, regardless of treatment response, is approximately 25 lymph nodes.Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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