Comparison of five-year survival and recurrence between three-field and two-field lymph node dissection in conversion surgery for esophageal squamous cell carcinoma_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

CHEN Hainan ¹ , XIONG Jicheng ¹ , LIANG Shuoming ² , LU Simiao ² , NIE Xinming ² , XIE Qin ² , LV Jiahua ³ , WANG Qifeng ³ , MIU Yan ² , HAN Yongtao ² ,  LENG Xuefeng ²

1. Department of Thoracic Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610054, P. R.China;
2. Department of Thoracic Surgery, Sichuan Clinical Research Center for Caner, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, 610041, P. R. China;
3. Department of Radiotherapy, Sichuan Clinical Research Center for Caner, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, 610041, P. R. China;

Corresponding?author：

LENG Xuefeng, Email: doc.leng@uestc.edu.cn

Keywords：

Esophageal cancer; conversion therapy; survival analysis; lymph node dissection; surgery

DOI：

10.7507/1007-4848.202510074

Video：

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Objective To evaluate the impact of three-field versus two-field lymph node dissection on postoperative complications and survival outcomes in patients with clinically unresectable esophageal squamous cell carcinoma undergoing conversion surgery. Methods Patients with esophageal squamous cell carcinoma who underwent conversion surgery at Sichuan Cancer Hospital between January 2018 and March 2020 were retrospectively included. Based on the extent of lymph node dissection, patients were divided into a three-field group and a two-field group. Postoperative complications, overall survival (OS), and disease-free survival (DFS) were compared between the two groups. Cox regression and Kaplan-Meier analysis were used to identify prognostic factors. Results A total of 58 patients were included, consisting of 51 males and 7 females, with a median age of 61.50 (53.25, 65.00) years. The three-field group comprised 17 patients, and the two-field group comprised 41 patients. The results showed that three-field lymph node dissection did not increase the risk of complications. The OS and DFS in the three-field group tended to be better than those in the two-field group, but the differences were not statistically significant (P=0.228, P=0.342). Cox regression analysis indicated that OS and DFS were not significantly correlated with the extent of lymph node dissection (P=0.234, P=0.347) but were associated with R0 resection status (P=0.027, P=0.069). Conclusion Three-field lymph node dissection demonstrates good safety and may provide survival benefits in specific patient subgroups. R0 resection is a key factor influencing surgical prognosis.

1.	Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin, 2024, 74(3): 229-263.
2.	Huang S, Wu H, Cheng C, et al. Conversion surgery following immunochemotherapy in initially unresectable locally advanced esophageal squamous cell carcinoma: a real-world multicenter study (RICE-Retro). Front Immunol, 2022, 13: 935374.
3.	冉興強, 施貴冬, 周瑜, 等. 不可切除食管鱗癌轉化手術的研究進展及前景. 中國胸心血管外科臨床雜志, 2024, 31(7): 1050-1057.Ran XQ, Shi GD, Zhou Y, et al. Advances and prospects of conversion surgery for unresectable esophageal squamous cell carcinoma. Chin J Clin Thorac Cardiovasc Surg, 2024, 31(7): 1050-1057.
4.	Matsuda S, Tsushima T, Kato K, et al. Defining conversion therapy for esophageal squamous cell carcinoma. Ann Gastroenterol Surg, 2023, 7(1): 7-9.
5.	Altorki N, Mynard N, Nasar A, et al. Ten-year survival and recurrence patterns after three-field lymph node dissection for squamous cell and adenocarcinoma of the esophagus. Ann Surg, 2023, 278(1): e43-e50.
6.	Isono K, Sato H, Nakayama K. Results of a nationwide study on the three-field lymph node dissection of esophageal cancer. Oncology, 1991, 48(5): 411-420.
7.	Altorki N, Kent M, Ferrara C, et al. Three-field lymph node dissection for squamous cell and adenocarcinoma of the esophagus. Ann Surg, 2002, 236(2): 177-183.
8.	Ma GW, Situ DR, Ma QL, et al. Three-field vs. two-field lymph node dissection for esophageal cancer: a meta-analysis. World J Gastroenterol, 2014, 20(47): 18022.
9.	Wang J, Yang Y, Shafiulla Shaik M, et al. Three-field versus two-field lymphadenectomy for esophageal squamous cell carcinoma: a meta-analysis. J Surg Res, 2020, 255: 195-204.
10.	Chan WL, Choi CW, Wong IYH, et al. Docetaxel, cisplatin, and 5-FU triplet therapy as conversion therapy for locoregionally advanced unresectable esophageal squamous cell carcinoma. Ann Surg Oncol, 2023, 30(2): 861-870.
11.	Ishikawa K, Nakamatsu K, Shiraishi O, et al. Clinical results of definitive-dose (50 Gy/25 fractions) preoperative chemoradiotherapy for unresectable esophageal cancer. Int J Clin Oncol, 2015, 20(3): 531-537.
12.	Takeuchi M, Kawakubo H, Mayanagi S, et al. The benefits of docetaxel plus cisplatin and 5-fluorouracil induction therapy in conversion to curative treatment for locally advanced esophageal squamous cell carcinoma. World J Surg, 2019, 43(8): 2006-2015.
13.	Pimiento JM, Weber J, Hoffe SE, et al. Outcomes associated with surgery for T4 esophageal cancer. Ann Surg Oncol, 2013, 20(8): 2706-2712.
14.	Sun JM, Shen L, Shah MA, et al. Pembrolizumab plus chemotherapy versus chemotherapy alone for first-line treatment of advanced oesophageal cancer (KEYNOTE-590): a randomised, placebo-controlled, phase 3 study. Lancet, 2021, 398(10302): 759-771.
15.	李少杰, 金悅, 孫清超, 等. 二野與三野淋巴結清掃術在食管癌根治術中的短期療效及遠期預后的meta分析. 中國醫藥科學, 2025, 15(4): 85-89,143.Li SJ, Jin Y, Sun QC, et al. Meta-analysis of short-term efficacy and long-term prognosis of two-field and three-field lymphadenectomy in radical resection of esophageal cancer. China Med Pharm, 2025, 15(4): 85-89,143.
16.	孫曾鋒, 劉軍強, 范博士, 等. 微創食管切除術聯合三野或二野淋巴結清掃術治療食管鱗狀細胞癌257例近期療效的回顧性隊列研究. 中國胸心血管外科臨床雜志, 2024, 31(4): 556-561.Sun CF, Liu JQ, Fan BS, et al. Short-term efficacy of minimally invasive esophagectomy combined with three-field versus two-field lymphadenectomy for 257 patients with esophageal squamous cell carcinoma: a retrospective cohort study. Chin J Clin Thorac Cardiovasc Surg, 2024, 31(4): 556-561.
17.	Bona D, Lombardo F, Matsushima K, et al. Three-field versus two-field lymphadenectomy for esophageal squamous cell carcinoma: a long-term survival meta-analysis. Surgery, 2022, 171(4): 940-947.
18.	Ohkura Y, Ueno M, Udagawa H. Advantageous factors of R0 curative conversion esophagectomy and the optimal extent of lymphadenectomy after induction therapy for cT4b thoracic esophageal cancer. Ann Gastroenterol Surg, 2021, 5(2): 204-214.
19.	Sugimura K, Miyata H, Tanaka K, et al. Multicenter randomized phase 2 trial comparing chemoradiotherapy and docetaxel plus 5-fluorouracil and cisplatin chemotherapy as initial induction therapy for subsequent conversion surgery in patients with clinical T4b esophageal cancer: short-term results. Ann Surg, 2021, 274(6): e465-e472.
20.	Gao LR, Li C, Han W, et al. Survival benefit of surgery in patients with clinical T4 esophageal cancer who achieved complete or partial response after neoadjuvant chemoradiotherapy or radiotherapy. Ther Adv Med Oncol, 2022, 14: 17588359221108693.
21.	Guo X, Chen C, Zhao J, et al. Neoadjuvant chemoradiotherapy vs. chemoimmunotherapy for esophageal squamous cell carcinoma. JAMA Surg, 2025, 160(5): 565.
22.	Xiong J, Lu S, Liang S, et al. Perineural invasion as a prognostic factor and the efficacy of upfront surgery for low-risk cT2/T3N0M0 esophageal squamous cell carcinoma patients. J Thorac Dis, 2025, 17(9): 6759-6770.
23.	Chen JW, Xie JD, Ling YH, et al. The prognostic effect of perineural invasion in esophageal squamous cell carcinoma. BMC Cancer, 2024, 14(1): 313.
24.	Gao A, Wang L, Li J, et al. Prognostic value of perineural invasion in esophageal and esophagogastric junction carcinoma: a meta-analysis. Dis Markers, 2016, 2016: 1-9.
25.	Bai L, Yan L, Guo Y, et al. Perineural invasion is a significant indicator of high malignant degree and poor prognosis in esophageal cancer: a systematic review and meta-analysis. Front Oncol, 2022, 12: 816270.
26.	Zhou J, Yang Y, Zhang H, et al. Lymphovascular and perineural invasion after neoadjuvant therapy in esophageal squamous carcinoma. Ann Thorac Surg, 2023, 115(6): 1386-1394.
27.	Lagarde SM, Phillips AW, Navidi M, et al. The presence of lymphovascular and perineural infiltration after neoadjuvant therapy and oesophagectomy identifies patients at high risk for recurrence. Br J Cancer, 2015, 113(10): 1427-1433.
28.	Guo YN, Tian DP, Gong QY, et al. Perineural invasion is a better prognostic indicator than lymphovascular invasion and a potential adjuvant therapy indicator for pN0M0 esophageal squamous cell carcinoma. Ann Surg Oncol, 2020, 27(11): 4371-4381.
29.	Ohkura Y, Ueno M, Iizuka T, et al. Prognostic factors and appropriate lymph node dissection in salvage esophagectomy for locally advanced T4 esophageal cancer. Ann Surg Oncol, 2019, 26(1): 209-216.
30.	Miyata H, Sugimura K, Motoori M, et al. Clinical implications of conversion surgery after induction therapy for T4b thoracic esophageal squamous cell carcinoma. Ann Surg Oncol, 2019, 26(13): 4737-4743.

1. Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin, 2024, 74(3): 229-263.
2. Huang S, Wu H, Cheng C, et al. Conversion surgery following immunochemotherapy in initially unresectable locally advanced esophageal squamous cell carcinoma: a real-world multicenter study (RICE-Retro). Front Immunol, 2022, 13: 935374.
3. 冉興強, 施貴冬, 周瑜, 等. 不可切除食管鱗癌轉化手術的研究進展及前景. 中國胸心血管外科臨床雜志, 2024, 31(7): 1050-1057.Ran XQ, Shi GD, Zhou Y, et al. Advances and prospects of conversion surgery for unresectable esophageal squamous cell carcinoma. Chin J Clin Thorac Cardiovasc Surg, 2024, 31(7): 1050-1057.
4. Matsuda S, Tsushima T, Kato K, et al. Defining conversion therapy for esophageal squamous cell carcinoma. Ann Gastroenterol Surg, 2023, 7(1): 7-9.
5. Altorki N, Mynard N, Nasar A, et al. Ten-year survival and recurrence patterns after three-field lymph node dissection for squamous cell and adenocarcinoma of the esophagus. Ann Surg, 2023, 278(1): e43-e50.
6. Isono K, Sato H, Nakayama K. Results of a nationwide study on the three-field lymph node dissection of esophageal cancer. Oncology, 1991, 48(5): 411-420.
7. Altorki N, Kent M, Ferrara C, et al. Three-field lymph node dissection for squamous cell and adenocarcinoma of the esophagus. Ann Surg, 2002, 236(2): 177-183.
8. Ma GW, Situ DR, Ma QL, et al. Three-field vs. two-field lymph node dissection for esophageal cancer: a meta-analysis. World J Gastroenterol, 2014, 20(47): 18022.
9. Wang J, Yang Y, Shafiulla Shaik M, et al. Three-field versus two-field lymphadenectomy for esophageal squamous cell carcinoma: a meta-analysis. J Surg Res, 2020, 255: 195-204.
10. Chan WL, Choi CW, Wong IYH, et al. Docetaxel, cisplatin, and 5-FU triplet therapy as conversion therapy for locoregionally advanced unresectable esophageal squamous cell carcinoma. Ann Surg Oncol, 2023, 30(2): 861-870.
11. Ishikawa K, Nakamatsu K, Shiraishi O, et al. Clinical results of definitive-dose (50 Gy/25 fractions) preoperative chemoradiotherapy for unresectable esophageal cancer. Int J Clin Oncol, 2015, 20(3): 531-537.
12. Takeuchi M, Kawakubo H, Mayanagi S, et al. The benefits of docetaxel plus cisplatin and 5-fluorouracil induction therapy in conversion to curative treatment for locally advanced esophageal squamous cell carcinoma. World J Surg, 2019, 43(8): 2006-2015.
13. Pimiento JM, Weber J, Hoffe SE, et al. Outcomes associated with surgery for T4 esophageal cancer. Ann Surg Oncol, 2013, 20(8): 2706-2712.
14. Sun JM, Shen L, Shah MA, et al. Pembrolizumab plus chemotherapy versus chemotherapy alone for first-line treatment of advanced oesophageal cancer (KEYNOTE-590): a randomised, placebo-controlled, phase 3 study. Lancet, 2021, 398(10302): 759-771.
15. 李少杰, 金悅, 孫清超, 等. 二野與三野淋巴結清掃術在食管癌根治術中的短期療效及遠期預后的meta分析. 中國醫藥科學, 2025, 15(4): 85-89,143.Li SJ, Jin Y, Sun QC, et al. Meta-analysis of short-term efficacy and long-term prognosis of two-field and three-field lymphadenectomy in radical resection of esophageal cancer. China Med Pharm, 2025, 15(4): 85-89,143.
16. 孫曾鋒, 劉軍強, 范博士, 等. 微創食管切除術聯合三野或二野淋巴結清掃術治療食管鱗狀細胞癌257例近期療效的回顧性隊列研究. 中國胸心血管外科臨床雜志, 2024, 31(4): 556-561.Sun CF, Liu JQ, Fan BS, et al. Short-term efficacy of minimally invasive esophagectomy combined with three-field versus two-field lymphadenectomy for 257 patients with esophageal squamous cell carcinoma: a retrospective cohort study. Chin J Clin Thorac Cardiovasc Surg, 2024, 31(4): 556-561.
17. Bona D, Lombardo F, Matsushima K, et al. Three-field versus two-field lymphadenectomy for esophageal squamous cell carcinoma: a long-term survival meta-analysis. Surgery, 2022, 171(4): 940-947.
18. Ohkura Y, Ueno M, Udagawa H. Advantageous factors of R0 curative conversion esophagectomy and the optimal extent of lymphadenectomy after induction therapy for cT4b thoracic esophageal cancer. Ann Gastroenterol Surg, 2021, 5(2): 204-214.
19. Sugimura K, Miyata H, Tanaka K, et al. Multicenter randomized phase 2 trial comparing chemoradiotherapy and docetaxel plus 5-fluorouracil and cisplatin chemotherapy as initial induction therapy for subsequent conversion surgery in patients with clinical T4b esophageal cancer: short-term results. Ann Surg, 2021, 274(6): e465-e472.
20. Gao LR, Li C, Han W, et al. Survival benefit of surgery in patients with clinical T4 esophageal cancer who achieved complete or partial response after neoadjuvant chemoradiotherapy or radiotherapy. Ther Adv Med Oncol, 2022, 14: 17588359221108693.
21. Guo X, Chen C, Zhao J, et al. Neoadjuvant chemoradiotherapy vs. chemoimmunotherapy for esophageal squamous cell carcinoma. JAMA Surg, 2025, 160(5): 565.
22. Xiong J, Lu S, Liang S, et al. Perineural invasion as a prognostic factor and the efficacy of upfront surgery for low-risk cT2/T3N0M0 esophageal squamous cell carcinoma patients. J Thorac Dis, 2025, 17(9): 6759-6770.
23. Chen JW, Xie JD, Ling YH, et al. The prognostic effect of perineural invasion in esophageal squamous cell carcinoma. BMC Cancer, 2024, 14(1): 313.
24. Gao A, Wang L, Li J, et al. Prognostic value of perineural invasion in esophageal and esophagogastric junction carcinoma: a meta-analysis. Dis Markers, 2016, 2016: 1-9.
25. Bai L, Yan L, Guo Y, et al. Perineural invasion is a significant indicator of high malignant degree and poor prognosis in esophageal cancer: a systematic review and meta-analysis. Front Oncol, 2022, 12: 816270.
26. Zhou J, Yang Y, Zhang H, et al. Lymphovascular and perineural invasion after neoadjuvant therapy in esophageal squamous carcinoma. Ann Thorac Surg, 2023, 115(6): 1386-1394.
27. Lagarde SM, Phillips AW, Navidi M, et al. The presence of lymphovascular and perineural infiltration after neoadjuvant therapy and oesophagectomy identifies patients at high risk for recurrence. Br J Cancer, 2015, 113(10): 1427-1433.
28. Guo YN, Tian DP, Gong QY, et al. Perineural invasion is a better prognostic indicator than lymphovascular invasion and a potential adjuvant therapy indicator for pN0M0 esophageal squamous cell carcinoma. Ann Surg Oncol, 2020, 27(11): 4371-4381.
29. Ohkura Y, Ueno M, Iizuka T, et al. Prognostic factors and appropriate lymph node dissection in salvage esophagectomy for locally advanced T4 esophageal cancer. Ann Surg Oncol, 2019, 26(1): 209-216.
30. Miyata H, Sugimura K, Motoori M, et al. Clinical implications of conversion surgery after induction therapy for T4b thoracic esophageal squamous cell carcinoma. Ann Surg Oncol, 2019, 26(13): 4737-4743.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Latest ArticlesComparison of five-year survival and recurrence between three-field and two-field lymph node dissection in conversion surgery for esophageal squamous cell carcinoma

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