Abstract: Objective To investigate the predictive value of preoperative albumin-to-fibrinogen ratio (A/F) for postoperative survival of esophageal squamous cell carcinoma after radical esophagectomy. Methods The retrospective cohort study was conducted. The clinicopathological data of 559 patients with esophageal squamous cell carcinoma who underwent radical resection in the Sun Yat-sen University Cancer Center from January 2009 and January 2012 were collected. There were 443 males and 116 females, aged from 53 to 66 years, with an average age of 59 years. Of 559 patients, 394 with A/F > 11.14 were in high A/F group, and 165 with A/F ≤ 11.14 were in low A/F group. Levels of plasma albumin and fibrinogen were measured at two weeks before surgery, and patients underwent radical esophagectomy. Observation indicators: (1) clinicopathological characteristics of patients; (2) survival of patients; (3) risk factors analysis of prognosis of patients. Follow-up was conducted by outpatient examination and telephone interview to detect postoperative survival of patients up to November 2018. The overall survival time was from surgery date to date of endpoint events including death or the last follow-up, and the overall disease-free survival time was from surgery date to date of endpoint events including tumor recurrence, tumor-ralted death, or the last follow-up. Measurement data with skewed distribution were expressed by M (range). Count data were described as percentage, and comparison between groups was analyzed using chi-square test or Fisher exact probability. Comparison of ordinal data was analyzed by Mann-Whitney U non-parametric test. The survival rate and curve were calculated and drawn by Kaplan-Meier method and the Log-rank test was used for survival analysis. The univariate and multivariate analyses were done using COX proportional hazard model. Results (1) Clinicopathological characteristics of patients: of 559 patients, cases with age ≤60 years and > 60 years, cases in T1 stage, T2 stage, T3 stage(depth of tumor invasion)were 246,148,60,79,255 in the high A/F group, and 79, 86, 5, 32,128 in the low A/F group, there were statistically significant differences in the age and depth of tumor invasion between the two groups (χ2=10.127, Z=-3.468, P<0.05). (2) Survival of patients: 559 patients were followed up for 97 months (range, 91-103 months). The 5-year overall survival rate and 5-year disease-free survival rate were 55.8% and 48.7% in the high A/F group, and 38.8% and 35.8% in the low A/F group, respectively, with statistically significant differences between the two groups (χ2=16.501, 11.679, P<0.05). (3) Risk factors analysis of prognosis of patients: results of univariate analysis showed that sex, age, preoperative fibrinogen level, preoperative A/F level, surgical method, depth of tumor invasion, tumor pathological N staging, and postoperative adjuvant therapy were associated with 5-year overall survival rate of esophageal squamous cell carcinoma after radical esophagectomy ［hazard ratio (HR) = 1.362, 1.358, 1.421, 0.617, 0.772, 1.490, 1.732, 1.436, 95% confidence interval (CI): 1.010-1.835, 1.084-1.700, 1.114-1.814, 0.487-0.781, 0.612-0.973, 1.239-1.792, 1.552-1.934, 1.128-1.829, P<0.05］; age, preoperative fibrinogen level, preoperative A/F level, surgical method, depth of tumor invasion, tumor pathological N staging, postoperative adjuvant therapy were associated with 5-year disease-free survival rate of esophageal squamous cell carcinoma after radical esophagectomy (HR=1.248, 1.371, 0.675, 0.740, 1.427, 1.665, 1.606, 95%CI: 1.006-1.547, 1.086-1.732, 0.538-0.847, 0.592-0.924, 1.202-1.695, 1.498-1.851, 1.275-2.022, P<0.05). Results of multivariate analysis showed that age, preoperative A/F level, surgical method, depth of tumor invasion, and tumor pathological N staging were independent factors for 5-year overall survival rate and 5-year disease-free survival rate of esophageal squamous cell carcinoma after radical esophagectomy (HR=1.491, 0.699, 0.741, 1.353, 1.761, 95%CI: 1.184-1.877, 0.550-0.888, 0.587-0.935, 1.120-1.634, 1.573-1.971, P<0.05; HR=1.372, 0.760, 0.703, 1.281, 1.692, 95%CI: 1.100-1.711, 0.603-0.957, 0.562-0.880, 1.074-1.527, 1.518-1.887, P<0.05). Conclusion Preoperative A/F level has a good predictive value for survival of esophageal squamous cell carcinoma after radical esophagectomy, and preoperative A/F level ≤ 11.14 is a independent risk factor for 5-year overall survival rate and 5-year disease-free survival rate of esophageal squamous cell carcinoma after radical esophagectomy.