Real-World Analysis of Neoadjuvant Immunochemotherapy Followed by Surgery in Esophageal Cancer with Baseline Supraclavicular Lymph Node Involvement.

BACKGROUND: Management of supraclavicular lymph node (SCLN) metastasis in esophageal cancer remains controversial. Neoadjuvant immunochemotherapy (nICT) may challenge current staging paradigms. This study evaluated prognosis of esophageal squamous cell carcinoma (ESCC) patients with baseline SCLN metastasis receiving nICT and surgery. METHODS: We retrospectively analyzed 335 ESCC patients (cT1-2N1-3 to T3-4aN0-3 or M1 [limited to SCLN]) receiving nICT and surgery between 2019 and 2021. Patients were stratified into cSCLN+ (n = 110) and cSCLN- (n = 225). Recurrence-free survival (RFS), overall survival (OS), and recurrence patterns were compared. Prognostic factors were assessed by using multivariable Cox regression. The impact of postoperative radiotherapy (PORT) was evaluated within the cSCLN+ subgroup. RESULTS: Pathological response rates were comparable between groups (pCR rates: 20.9% vs. 27.6%, p = 0.238). At a median follow-up of 23.8 months, no significant differences in RFS (p = 0.109) and OS (p = 0.859) were observed, with similar recurrence patterns. Multivariable analysis showed cSCLN status was not an independent prognostic factor. Nevertheless, patients with persistent pathological SCLN positivity (cSCLN+pSCLN+) experienced significantly worse survival (median RFS 12.4 months, median OS 40.4 months; both not reached in other groups). Upper-thoracic tumor and advanced pathological nodal stage were independent risk factors in cSCLN+ cohort. Although PORT did not significantly improve survival in the overall cSCLN+ population, a trend toward improved OS was observed in the cSCLN+pSCLN+ subgroup. CONCLUSIONS: Esophageal squamous cell carcinoma patients with clinically positive SCLN might achieve comparable prognosis to those with clinically negative nodes after nICT plus surgery. For patients with residual pathological SCLN positivity, PORT may be considered as a potential strategy to improve survival outcomes.