Yifei Lu,1,* Minhua Ye,2,* Dehua Ma,2 Yu Chen2 

1Department of Cardiology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, People’s Republic of China; 2Department of Thoracic Surgery, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, People’s Republic of China

*These authors contributed equally to this work

Correspondence: Yu Chen; Dehua Ma, Email chenyu5835@126.com; madh@enzemed.com

Objective: To explore the association between survival status and the number of resected lymph nodes in node-negative esophageal squamous cell carcinoma(ESCC) after surgical treatment.
Methods: This was a retrospective observational cohort study and data were obtained from the Surveillance, Epidemiology, and End Results program (SEER) and TaiZhou hospital in China. The data for subjects with negative lymph nodes and no distant metastasis (pN0M0) after post-operative pathology were screened. The nonlinear relationship between resected lymph node number and survival status in node-negative ESCC was conducted using restricted cubic spline regression analysis. The association between the number of resected lymph nodes and survival status in node-negative ESCC was evaluated by Cox proportional hazards regression models. Subgroup analysis based on different subgroups was also performed.
Results: A total of 999 subjects were included in the study. Restricted cubic spline regression was used to show a U shaped association between the number of resected lymph nodes and survival status in node-negative ESCC, with low count associated with a decreased survival. To elucidate the association, we adjusted for age, sex, race, T stage, TNM (tumor node metastasis classification), location, grade, chemotherapy, and radiotherapy. As the resected lymph node number increased by one node, the survival status was improved by 2% (Hazard ratio(HR) = 0.98, 95% confidence interval (CI) 0.98– 0.99). Sensitivity analysis indicate that the effect size and direction in different subgroups are consistent, the results is stability in SEER.
Conclusion: A low count of resected lymph nodes correlated with reduced survival in patients with ESCC, where resecting 25 to 28 or more nodes is considered optimal. Larger prospective studies are warranted to confirm these findings.

Keywords: number of lymph node resection, survival status, cohort study, nonlinear relationship, node-negative esophageal squamous cell carcinoma