Neoadjuvant Therapy and Surgery vs. Upfront Surgery: A Comparative Study in Clinical T2n0 Esophageal Squamous Cell Carcinoma

Background Esophageal cancer is the ninth most common cancer worldwide and the sixth leading cause of cancer-related death. T1bN0M0 esophageal cancer is treated surgically, while advanced stages (pT3–4 or N+) are commonly managed with neoadjuvant chemoradiation followed by surgery, which is widely accepted as the standard treatment. However, the optimal treatment for T2N0M0 esophageal cancer remains controversial. The National Comprehensive Cancer Network guidelines recommend neoadjuvant chemoradiation for cases with poor prognostic pathological features. This study aims to analyze short-term pathological results and compare long-term oncological outcomes between upfront surgery and trimodality treatment in cT2N0 esophageal squamous cell carcinoma. Methods This retrospective study reviewed patients who underwent esophagectomy between January 2006 and December 2020. Patients with concurrent malignancies were excluded. Disease-free survival and overall survival were compared between those receiving neoadjuvant chemoradiation followed by surgery; trimodality treatment and those undergoing upfront surgery. The upfront surgery group was subdivided into three groups based on pathological T and N stages: pDownstage (pT0–1 N0), pT2N0, and pUpstage (pT3–4 or N+). Radical esophagectomy was performed using either the Ivor Lewis or McKeown approach, depending on tumor location relative to the carina. Results Out of 1768 esophagectomy patients, 228 had clinical T2N0 squamous cell carcinoma, with 23 excluded due to concurrent malignancies. The upfront surgery group consisted of 134 patients, while the trimodality treatment group included 71 patients. There was no difference in overall survival (p = 0.164) or disease-free survival (p = 0.592) between the groups. In the upfront surgery group, 53 patients (39.6%) were pDownstage, 23 patients (17.2%) were pT2N0, and 58 patients (43.3%) were pUpstage. Patients in the pT2N0 and pUpstage groups had significantly worse disease-free survival compared to the pDownstage group (p = 0.041). Conclusion In conclusion, upfront surgery for cT2N0 esophageal squamous cell carcinoma offers similar overall and disease-free survival rates compared to patients who undergo neoadjuvant chemoradiation followed by surgery. However, clinical staging alone may not be sufficiently accurate, and a significant proportion of cT2N0 patients are pathologically upstaged. These patients may have benefitted from neoadjuvant therapy. Further modalities for preoperative staging, such as MRI of the chest, endobronchial ultrasound or patholgical confirm of metastatic nodes should be considered to improve accuracy. Accurate staging ensures that patients receive the most appropriate treatment.