Impact of lymph node dissection on survival after neoadjuvant immunochemotherapy for esophageal squamous cell cancer: a double-center real-world retrospective study

Previous studies indicated that over-dissection of lymph nodes might impair the efficacy of immunotherapy. This study aims to explore the prognostic value of ypN + status and the impact of lymph node dissection (LND) on survival after neoadjuvant immunochemotherapy (NICT) for esophageal squamous cell cancer (ESCC). This double-center retrospective study enrolled 206 consecutive ESCC patients who underwent NICT followed by esophagectomy between 2018 and 2024. Overall survival (OS) and disease-free survival (DFS) were compared based on ypN/ypT status and LND count. Cutoff values for LND were determined by restricted cubic spline (RCS) analysis based on Cox regression models. ypN + status was significantly associated with worse OS (3-year OS: 69.3% vs. 92.8%, p = 0.0063) and DFS (3-year DFS: 52.4% vs. 85.3%, p < 0.001) compared to ypN0. Multivariate Cox analysis confirmed ypN status (ypN2: OS HR = 8.510, p < 0.001; DFS HR = 8.162, p < 0.001. ypN3 DFS HR = 18.82, p = 0.001) as a stronger independent prognostic factor than ypT status. RCS curves identified the cutoff values of 32 and 48 for LND. Patients with 32 < LND ≤ 48 had the best OS and DFS. LND > 48 was associated with significantly worse OS (p = 0.033) and DFS (p = 0.025) compared to 32 < LND ≤ 48. Although not statistically significant, the LND > 48 group had higher rates of total complications (52.3% vs. 42.6%; p = 0.330). ypN status is a more powerful prognostic factor than ypT status in ESCC patients treated with NICT and surgery. LND exceeding 48 nodes is associated with diminished survival. An optimal LND range of 32 to 48 nodes is recommended to balance accurate staging, therapeutic benefit, and preservation of immune function.