Abstract
BACKGROUND: Patients with esophageal squamous cell carcinoma (ESCC) with lymph node metastasis may be misclassified as pN0 due to an insufficient number of lymph nodes examined (LNE). The purpose of this study was to confirm that patients with ESCC are indeed pN0 and to propose an adequate number for the correct nodal stage using the nodal staging score (NSS) developed by the beta-binomial model. METHODS: A total of 1249 patients from the Surveillance, Epidemiology, and End Results (SEER) database between 2000 and 2017, and 1404 patients diagnosed with ESCC in our database between 2005 and 2018 were included. The NSS was developed to assess the probability of pN0 status based on both databases. The effectiveness of NSS was verified using survival analysis, including Kaplan-Meier curves and Cox models. RESULTS: Many patients were misclassified as pN0 based on our algorithm due to insufficient LNE. As the number of LNE increased, false-negative findings dropped; accordingly, the NSS increased. In addition, NSS was an independent prognostic indicator for pN0 in patients with ESCC in the SEER database (hazard ratio [HR] 0.182, 95% confidence interval [CI] 0.046-0.730, p = 0.016) and our database (HR 0.215, 95% CI 0.055-0.842, p = 0.027). A certain number of nodes must be examined to achieve 90% of the NSS. CONCLUSIONS: NSS could determine the probability of true pN0 status for patients, and it was sufficient in predicting survival and obtaining adequate numbers for lymphadenectomy.