Standard for the Surgical Treatment of Esophageal Cancer
Standard for the Surgical Treatment of Esophageal Cancer
Objective To analyze survival differences between transthoracic esophagectomy (TTE) and limited transhiatal esophagectomy (THE) in clinically (cT3) and pathologically (pT3) staged advanced tumors without neoadjuvant treatment.
Background Debate exists whether in the type of resection in locally advanced cancer plays a role in prognosis and whether THE is a valuable alternative to TTE regarding oncological doctrine and overall survival.
Methods In a retrospective study of 2 high-volume centers, 468 patients with cT3NXM0 esophageal cancer, including 242 (51.7%) squamous cell carcinomas (SCCs) and 226 (48.3%) adenocarcinomas (ACs), were analyzed. A total of 341 (72.9%) TTE and 127 (27.1%) THE were performed. We used the propensity score matching to build comparable groups. Primary endpoint was the overall survival; secondary endpoints included resection status and lymph node yield.
Results TTE achieved a higher rate of R0 resections (86.2% vs 73.2%; P = 0.001) and a higher median lymph node yield (27.0 ± 12.4 vs 17.0 ± 6.4; P < 0.001) than THE. Thirty-day mortality rate was 6.6% (8/121) for TTE and 7.4% (9/121) for THE (P = 0.600). In the matched groups, TTE was beneficial for pT3 SCC (P = 0.004), pT3 AC (P = 0.029), cT3 SCC (P = 0.018), and cT3 AC (P = 0.028) patients. TTE was either beneficial in pN2 disease for cT3 AC + SCC or pT3 SCC but not for pT3 AC patients, without nodal stratification in pT3 and cT3 SCC node-positive patients. On multivariable analysis, TTE remained an independent factor for survival.
Conclusions Extended TTE achieved a higher rate of R0 resections, a higher lymph node yield, and resulted in a prolonged survival than THE in pT3, cT3, and node-positive patients.
Esophagectomy is the main treatment of potentially curable esophageal cancer (EC), but considerable debate exists about the most appropriate surgical approach. Because esophagectomy is a highly demanding procedure for patients in terms of perioperative complications and postsurgical impairments per se, limited transhiatal resection aimed to reduce the perioperative morbidity and mortality, but the oncological quality was thought to be compromised by insufficient mediastinal lymph node clearance. The extended transthoracic resection was advocated for its extended lymph node clearance, wide tumor excision, and supposedly superior long-term outcomes.
The role of neoadjuvant chemoradiotherapy has been debated for several decades. In most randomized trials, no survival benefit could be shown and the trials were criticized for inadequate trial design, frequently applied different surgical strategies [eg, radical transthoracic esophagectomy (TTE), transhiatal esophagectomy (THE)], small sample sizes, and poor outcomes in the surgery-alone group. Meta-analyses suggest a marginal survival benefit from neoadjuvant chemoradiotherapy of 7% to 9%, albeit frequently at the cost of increased postoperative morbidity and mortality.
In existing randomized controlled trials assessing neoadjuvant regimens compared with surgery alone, both radical and limited resections were performed, with predominance of the limited transhiatal resection and an observed wide variance in R0 resection rates. Consequently, a long-term survival comparison between radical and limited surgical resections in patients with similar neoadjuvant therapy was prohibited.
Therefore, to address the question which approach has the potential for long-term survival advantages in advanced tumors, this 2-center study was conducted only in patients without neoadjuvant treatment. Furthermore, a propensity score matching was done to decrease potential biases of confounding effects of covariates. Pathologically (pT3) and clinically (cT3) staged advanced tumors of both tumor types were analyzed separately to define the superiority of one procedure over the other, to establish a given surgical procedure as the gold standard for future comparisons with neoadjuvant or innovative treatment strategies.
Abstract and Introduction
Abstract
Objective To analyze survival differences between transthoracic esophagectomy (TTE) and limited transhiatal esophagectomy (THE) in clinically (cT3) and pathologically (pT3) staged advanced tumors without neoadjuvant treatment.
Background Debate exists whether in the type of resection in locally advanced cancer plays a role in prognosis and whether THE is a valuable alternative to TTE regarding oncological doctrine and overall survival.
Methods In a retrospective study of 2 high-volume centers, 468 patients with cT3NXM0 esophageal cancer, including 242 (51.7%) squamous cell carcinomas (SCCs) and 226 (48.3%) adenocarcinomas (ACs), were analyzed. A total of 341 (72.9%) TTE and 127 (27.1%) THE were performed. We used the propensity score matching to build comparable groups. Primary endpoint was the overall survival; secondary endpoints included resection status and lymph node yield.
Results TTE achieved a higher rate of R0 resections (86.2% vs 73.2%; P = 0.001) and a higher median lymph node yield (27.0 ± 12.4 vs 17.0 ± 6.4; P < 0.001) than THE. Thirty-day mortality rate was 6.6% (8/121) for TTE and 7.4% (9/121) for THE (P = 0.600). In the matched groups, TTE was beneficial for pT3 SCC (P = 0.004), pT3 AC (P = 0.029), cT3 SCC (P = 0.018), and cT3 AC (P = 0.028) patients. TTE was either beneficial in pN2 disease for cT3 AC + SCC or pT3 SCC but not for pT3 AC patients, without nodal stratification in pT3 and cT3 SCC node-positive patients. On multivariable analysis, TTE remained an independent factor for survival.
Conclusions Extended TTE achieved a higher rate of R0 resections, a higher lymph node yield, and resulted in a prolonged survival than THE in pT3, cT3, and node-positive patients.
Introduction
Esophagectomy is the main treatment of potentially curable esophageal cancer (EC), but considerable debate exists about the most appropriate surgical approach. Because esophagectomy is a highly demanding procedure for patients in terms of perioperative complications and postsurgical impairments per se, limited transhiatal resection aimed to reduce the perioperative morbidity and mortality, but the oncological quality was thought to be compromised by insufficient mediastinal lymph node clearance. The extended transthoracic resection was advocated for its extended lymph node clearance, wide tumor excision, and supposedly superior long-term outcomes.
The role of neoadjuvant chemoradiotherapy has been debated for several decades. In most randomized trials, no survival benefit could be shown and the trials were criticized for inadequate trial design, frequently applied different surgical strategies [eg, radical transthoracic esophagectomy (TTE), transhiatal esophagectomy (THE)], small sample sizes, and poor outcomes in the surgery-alone group. Meta-analyses suggest a marginal survival benefit from neoadjuvant chemoradiotherapy of 7% to 9%, albeit frequently at the cost of increased postoperative morbidity and mortality.
In existing randomized controlled trials assessing neoadjuvant regimens compared with surgery alone, both radical and limited resections were performed, with predominance of the limited transhiatal resection and an observed wide variance in R0 resection rates. Consequently, a long-term survival comparison between radical and limited surgical resections in patients with similar neoadjuvant therapy was prohibited.
Therefore, to address the question which approach has the potential for long-term survival advantages in advanced tumors, this 2-center study was conducted only in patients without neoadjuvant treatment. Furthermore, a propensity score matching was done to decrease potential biases of confounding effects of covariates. Pathologically (pT3) and clinically (cT3) staged advanced tumors of both tumor types were analyzed separately to define the superiority of one procedure over the other, to establish a given surgical procedure as the gold standard for future comparisons with neoadjuvant or innovative treatment strategies.
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