Extracapsular lymph node involvement is a negative prognostic factor after neoadjuvant chemoradiotherapy in locally advanced esophageal cancer.

Introduction: To assess prognosis depending on whether lymph node involvement (LNI) is intracapsular or with extracapsular breakthrough in patients with a locally advanced esophageal cancer treated with neoadjuvant chemoradiation and surgery.

Methods: Ninety-four consecutive patients with an esophageal cancer staged IIB (n = 17) and III (n = 77) received neoadjuvant chemoradiation followed by transthoracic esophagectomy with two-field lymphadenectomy. Histology was squamous cell carcinoma (n = 46) and adenocarcinoma (n = 48). Neoadjuvant therapy consisted of association of 5-fluorouracil/cisplatin concomitantly with a 45-Gy radiation therapy. Disease-free survival (DFS) excluding the in-hospital mortality was analyzed according to the nodal status and the invaded/resected lymph node ratio (LNR). Clinical factors affecting survival or predictors of extracapsular invasion were investigated by multivariate analysis.

Results: Five-year DFS rates were 46, 36, and 11% in N0 patients (n = 56), intracapsular LNI patients (n = 18), and extracapsular LNI patients (n = 10), respectively (p = 0.002). Intracapsular LNI patients with an LNR <0.1 (n = 12) had a 5-year DFS rate similar to N0 patients (44 versus 46%, p = 0.95). Intracapsular LNI patients with an LNR > or =0.1 (n = 6) had a DFS rate similar to extracapsular LNI patients (18 versus 11%, p = 0.69). Multivariate analysis revealed that the sole independent factor affecting DFS was the extracapsular LNI (HR = 3.9, p = 0.026). The number of invaded LN seemed to be the sole significant predictive factor for the development of ECLNI (HR = 2.39, p = 0.008).

Conclusion: After neoadjuvant chemoradiotherapy, there was a significant difference on DFS depending on whether LNI was intracapsular or extracapsular. Extracapsular invasion seems to be an independent negative prognostic factor affecting survival, and its presence is related to the number of invaded LN.