Upstaging Risk and Prognosis of Clinical T2-3N0M0 Esophageal Squamous Cell Carcinoma Patients after a Curative Esophagectomy: A Propensity Score-Matched Analysis

Background: Neoadjuvant chemoradiation therapy (nCRT) has survival benefits for patients
with cT1N1 or cT2–3N0-1 esophageal squamous cell carcinoma (ESCC), but heterogeneous
disease behavior has been observed in node-negative tumors. This study aimed
to investigate the risk of upstaging and the efficacy of upfront esophagectomy compared
with nCRT followed by surgery in patients with cT2–3N0 ESCC.
Methods: ESCC patients treated at Taipei Veterans General Hospital, Taiwan, between
January 2010 and December 2022 were retrospectively reviewed. Patients who underwent
upfront surgery (n=72) and those who received neoadjuvant therapy (n=36) were
included in this analysis on an intention-to-treat basis after propensity score matching.
Comparisons of TNM (tumor, node, and metastasis) classification shifts between patients
who underwent upfront surgery and those who received neoadjuvant therapy, as well as
primary outcomes including overall survival (OS) and recurrence-free survival (RFS), were
analyzed.
Results: Among patients who underwent upfront surgery, 6 (16.7%) in the cT2 group and
10 (27.8%) in the cT3 group had occult lymph node (LN) metastasis. Most patients (77.4%)
who received neoadjuvant therapy experienced downstaging; however, there were no
significant differences in OS (5-year OS: 53.8% vs. 51.6%, p=0.666) or RFS (5-year RFS: 48.6%
vs. 44.8%, p=0.864) compared with upfront surgery. No significant differences were observed
before propensity score matching for either OS (p=0.809) or RFS (p=0.856).
Conclusion: Upfront esophagectomy in patients with cT2–3N0 ESCC provides comparable
survival outcomes, despite the higher risk of upstaging and occult LN metastasis.