Does Pseudo-Lymph Node Skip Metastasis After Neoadjuvant Therapy Affect Esophageal Squamous Cell Carcinoma Outcomes?—a Multicenter Study

Background Unlike classical lymph node skip metastasis, pseudo-lymph node skip metastasis occurs when proximal lymph nodes show therapeutic alleviation while distal lymph nodes remain positive in esophageal squamous cell carcinoma after neoadjuvant therapy. This multicenter study aims to investigate the prognostic value of pseudo-lymph node skip metastasis. Methods We analyzed 1030 patients with esophageal cancer treated with neoadjuvant therapy followed by esophagectomy at three tertiary centers in China from 2010 to 2023. Lymph node skip metastasis categorization was based on Japan Esophagus Society staging system, which classifies lymph node metastasis based on specific lymph node stations involved. Results Overall skip metastasis showed no significant prognostic difference from non-skip metastasis. However, distinguish overall lymph node skip metastasis into classical lymph node skip metastasis and pseudo-lymph node skip metastasis revealed that patients with lymph node skip metastasis had better overall and disease-free survival compared to those with non-skip metastasis, whereas patients with pseudo-lymph node skip metastasis had worse outcomes. Pseudo-lymph node skip metastasis emerged as an independent prognostic factor for overall and disease-free survival, while lymph node skip metastasis independently predicted disease-free survival. Nomograms based on lymph node skip metastasis status effectively predicted overall and disease-free survival. Conclusion This finding suggests that clinicians should exercise caution when evaluating lymph node skip metastasis in esophageal squamous cell carcinoma receiving neoadjuvant therapy, as the prognostic implications of classical lymph node skip metastasis and pseudo-lymph node skip metastasis are completely opposite. Prediction models based on lymph node skip metastasis status aid individualized decision-making for clinicians.