Patterns of recurrence after esophagectomy following neoadjuvant Immunochemotherapy for esophageal squamous cell carcinoma.
Authors: An Qiuying , Zhang Ping , Bai Wenwen , Zhen Chanjun , Liu Sihan , Ji Hongshan , Zhang Zihan , Fu Liyuan , Wang Jun , Wang Hongyan , Liu Qingyi , Zhu Hui , Wang Yajing , Su Yuhao , Si Hanyu , Jia Yage , Zhou Zhiguo 
Published: July 2024

e16101

Background: To explore the recurrence pattern and risk factors of the initial relapse for esophageal squamous cell carcinoma (ESCC) who received radical surgery following neoadjuvant Immunochemotherapy (NICT). Methods: We reviewed 191 ESCC patients who underwent radical surgery following NICT from 2020 to 2022. The pattern of the first postoperative failure and simple lymph node (LN) recurrence were analyzed. Risk factors for failure were analyzed using logistic multivariate regression. Postoperative recurrence-free survival (RFS) was determined using the Kaplan-Meier method, and the log-rank test was applied to assess differences. Results: Until November 26, 2023, 66 of 191 patients experienced postoperative failure. The failure rates at 6 months, 1 year and 2 years were 7.3%, 21.0% and 37.4%, respectively. The overall recurrence pattern included single-pattern recurrence (84.8%) and multiple-pattern recurrence (15.2%). Among the single-pattern recurrence, simple LN recurrence (77%) was the most common. In total, 112 recurrent areas were observed in 43 patients with simple LN recurrence, and the failure rates of cervical, mediastinal and abdominal LNs were 15%, 70% and 15%, respectively. In patients with mediastinal LN failure, superior mediastinal LN recurrence accounted for the highest proportion (54%,60/112), of which 2R (16%,18/112) and 4R (14%,16/112) were the most frequent. The highest proportion (71.4%) of LN failure was located outside the scope of surgical dissection, and the highest incidence was in the supraclavicular area (21%) and the mediastinal 4R area (20%). According to the number of dissected LN areas, patients were divided into three groups: 1-6≤, 6-9≤, and 9-14≤. The 2-year RFS rates for three groups were 50.5%, 72.3%, and 63.5%, respectively (P = 0.04). According to the number of dissected LNs, patients were divided into three groups: 15 < , 15-30 < , and ≥30. The 2-year RFS rates of the three groups were 49.7%, 61.6%, and 71.6%, respectively (P = 0.28). Subgroup analysis showed that the 2-year RFS rates in ypT0-1N0 patients were 80%, 90% and 78.4% (P = 0.56), respectively, and ypT0-1N0 patients with more than 30 LNs did not show significant advantage. Multivariate analysis showed that tumor length > 5 cm, preoperative efficacy evaluation of stable disease (SD), number of dissected LN areas≤6, and ypN2-3 stage were unfavorable factors for postoperative failure in patients. Conclusions: LN recurrence is a common failure mode after radical surgery following NICT for ESCC, and the LN recurrence in the mediastinal 4R and 2R regions is the most common. Tumor length > 5cm, preoperative efficacy evaluation of SD, number of dissected LN areas≤6, and ypN2-3 stage were unfavorable factors for postoperative failure in patients. The suitability of extensive and multiple LN dissection after NICT in ESCC remains to be further investigated.