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Nodal yield <15 is associated with reduced survival in esophagectomy and is a quality metric.

BACKGROUND: Surgical resection following neoadjuvant therapy remains the cornerstone of curative management of esophageal adenocarcinoma, and is frequently used for squamous cell carcinoma. The optimal extent of lymphadenectomy, and whether increasing lymph node yields confers a survival benefit remains unclear. Guidelines suggest resecting and examining a minimum of 15 lymph nodes at esophagectomy. This study assesses the impact of lymph node yield and lymph node ratio (LNR) on survival, identifying factors influencing nodal yield and radicality of resection.

METHODS: All patients undergoing esophagectomy with curative intent at a single institution (stage I-stage IV inclusive) from January 1, 2010 to December 31, 2020 were reviewed. Clinical and pathological variables were interrogated. LNR is calculated by dividing positive lymph nodes by the total nodes resected.

RESULTS: 397 patients underwent esophagectomy, with 288 undergoing minimally invasive esophagectomy (MIE). Margin status (1.80 (1.15-2.83),p<0.01), nodal yield <15 (HR: 1.98 (1.29-3.04) p=0.002) and elevated LNR (HR: 8.16 (2.89-23.06), p<0.001) predicted survival. MIE had higher nodal yields compared with open procedures (30.7 vs 25.3, p<0.001). Patients undergoing neoadjuvant chemoradiation had lower nodal yields compared with those with no neoadjuvant therapy and those with neoadjuvant chemotherapy (26.4 vs 30.6 vs 36.8 respectively, p<0.001). Regression analysis determined LNR <0.05 was associated with a survival benefit.

CONCLUSIONS: Textbook lymphadenectomy is associated with improved survival. Low lymph node yield and high LNR are associated with reduced overall survival. A LNR of <0.05 is associated with significant survival benefit. A minimum nodal yield of 15 should remain the standard of care.

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