Three-field lymph node dissection subsequent to neoadjuvant concurrent chemoradiotherapy in esophageal cancer

BACKGROUND: In esophageal squamous cell carcinoma, three-field lymph node dissection (3FLND) is not commonly performed after neoadjuvant chemoradiotherapy (nCRT) due to the high morbidity associated with the procedure and the poor long-term survival of patients with cervical/supraclavicular lymph node metastasis. This study aims to evaluate the long-term survival outcomes of patients who underwent 3FLND combined with nCRT. METHODS: Between 2013 and 2021, patients who underwent esophagectomy and 3FLND after nCRT for advanced thoracic esophageal squamous cell carcinoma, either with (n = 41) or without (n = 65) clinical cervical/supraclavicular lymph node metastasis, were included in this study. RESULTS: The Ivor Lewis and McKeown procedures were performed in 22 patients (20.8%) and 84 patients (79.2%), respectively. The rates of major complications (Grade ≥ IIIb) and 90-day mortality were 6.6% and 2.8%, respectively. A pathological complete response was observed in 26 patients (24.5%), whereas residual cervical/supraclavicular lymph node metastasis was identified in 30 patients (28.3%). The five-year overall survival rates for patients with and without preoperative cervical/supraclavicular lymph node metastasis were 51.5% and 41.4%, respectively. Multivariable analysis of survival in patients with preoperative cervical/supraclavicular lymph node metastasis identified residual cervical/supraclavicular lymph node metastasis (hazard ratio [HR] = 7.885, P < 0.001) and major complications (HR = 74.581, P = 0.001) as significant risk factors for overall survival. CONCLUSIONS: 3FLND combined with nCRT can achieve favorable long-term survival even in patients with esophageal cancer and cervical/supraclavicular lymph node metastasis. Downstaging of cervical lymph node metastasis is a key factor in improving survival outcomes for these patients.