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Kramer SP, Swanson J, Fernando M, Park S, Verm R, Abdelsattar Z, Cohn T, Luchette FA, Baker MS. Locally Advanced Adenocarcinoma of the Esophagus: Is Esophagectomy Associated with Improved Overall Survival? J Am Coll Surg 2024; 239:68-75. [PMID: 38483131 DOI: 10.1097/xcs.0000000000001073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
BACKGROUND Esophagectomy in locally advanced esophageal adenocarcinoma is challenging and carries risk. The value of esophagectomy in locally advanced esophageal adenocarcinoma is not well-defined. STUDY DESIGN The National Cancer Database was used to identify patients with cT4 esophageal adenocarcinoma from 2004 to 2020. Multivariable regression was used to identify factors associated with use of esophagectomy. Cox modeling was used to identify factors associated with all-cause mortality. Patients undergoing esophagectomy were 1:1 propensity score-matched to patients treated nonsurgically. Kaplan-Meier analysis was used to compare 5-year overall survival (OS). RESULTS A total of 3,703 patients met inclusion criteria. Of those, 541 (15%) underwent esophagectomy, and 3,162 (85%) did not. Age 65 years or less (adjusted odds ratio [aOR] 1.69, 95% CI 1.33 to 2.14), White race (aOR 2.98, 95% CI 2.24 to 3.96), treatment in academic centers (aOR 1.64, 95% CI 1.33 to 2.02), private insurance (aOR 1.88, 95% CI 1.50 to 2.36), and tumors less than 6 cm (aOR 1.86, 95% CI 1.44 to 2.40) were associated with use of esophagectomy. Government of lack of insurance (hazard ratio [HR] 1.23, 95% CI 1.12 to 1.35), income <$46,000 (HR 1.11, 95% CI 1.03 to 1.20), treatment in nonacademic centers (HR 1.16, 95% CI 1.07 to 1.25), Charlson-Deyo Comorbidity Index 1 or more (HR 1.22, 95% CI 1.12 to 1.32), and tumors 6 cm or more (HR 1.20, 95% CI 1.09 to 1.32) were associated with risk of all-cause mortality. Esophagectomy (HR 0.50, 95% CI 0.44 to 0.56) and systemic therapy (HR 0.40, 95% CI 0.37 to 0.43) were associated with decreased risk of all-cause mortality. Patients undergoing esophagectomy had higher rates of 5-year OS (27.4% vs 13.2%, p < 0.0001) and longer median OS (24.71 vs 10.09 months, p < 0.0001). Among cT4b patients, those who underwent esophagectomy had higher rates of 5-year OS (24.5% vs 12.3%, p < 0.0001) and longer median OS (25.53 vs 11.01 months, p < 0.0001). CONCLUSIONS In cT4 esophageal adenocarcinoma, esophagectomy is associated with improved rates of 5-year OS compared with nonsurgical treatment.
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Affiliation(s)
- Sarah P Kramer
- From the Department of Surgery, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY (Kramer)
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL (Kramer, Swanson, Fernando, Park)
| | - James Swanson
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL (Kramer, Swanson, Fernando, Park)
| | - Mitchel Fernando
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL (Kramer, Swanson, Fernando, Park)
| | - Simon Park
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL (Kramer, Swanson, Fernando, Park)
| | - Raymond Verm
- Thoracic and Cardiovascular Surgery (Verm, Abdelsattar), Loyola University Medical Center, Maywood, IL
| | - Zaid Abdelsattar
- Thoracic and Cardiovascular Surgery (Verm, Abdelsattar), Loyola University Medical Center, Maywood, IL
| | - Tyler Cohn
- Departments of Surgery (Cohn, Luchette, Baker), Loyola University Medical Center, Maywood, IL
- Department of Surgery, Edward Hines Jr Veterans Affairs Hospital, Hines, IL (Cohn, Luchette)
| | - Fred A Luchette
- Departments of Surgery (Cohn, Luchette, Baker), Loyola University Medical Center, Maywood, IL
- Department of Surgery, Edward Hines Jr Veterans Affairs Hospital, Hines, IL (Cohn, Luchette)
| | - Marshall S Baker
- Departments of Surgery (Cohn, Luchette, Baker), Loyola University Medical Center, Maywood, IL
- Department of Surgery, University of Utah Health, Salt Lake City, UT (Baker)
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Bandidwattanawong C. Multi-disciplinary management of esophageal carcinoma: Current practices and future directions. Crit Rev Oncol Hematol 2024; 197:104315. [PMID: 38462149 DOI: 10.1016/j.critrevonc.2024.104315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/30/2024] [Accepted: 02/26/2024] [Indexed: 03/12/2024] Open
Abstract
Esophageal cancer in one of the most malignant and hard-to-treat cancers. Esophageal squamous carcinoma (ESCC) is most common in Asian countries, whereas adenocarcinoma at the esophago-gastric junction (EGJ AC) is more prevalent in the Western countries. Due to differences in both genetic background and response to chemotherapy and radiotherapy, both histologic subtypes need different paradigms of management. Since the landmark CROSS study has demonstrated the superior survival benefit of tri-modality including neoadjuvant chemoradiotherapy prior to esophagectomy, the tri-modality becomes the standard of care; however, it is suitable for a highly-selected patient. Tri-modality should be offered for every ESCC patient, if a patient is fit for surgery with adequate cardiopulmonary reserve, regardless of ages. Definitive chemoradiotherapy remains the best option for a patient who is not a surgical candidate or declines surgery. On the contrary, owing to doubtful benefits of radiotherapy with potentially more toxicities related to radiotherapy in EGJ AC, either neoadjuvant chemotherapy or peri-operative chemotherapy would be more preferable in an EGJ AC patient. In case of very locally advanced disease (cT4b), the proper management is more challenging. Even though, palliative care is the safe option, multi-modality therapy with curative intent like neoadjuvant chemotherapy with conversion surgery may be worthwhile; however, it should be suggested on case-by-case basis.
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Affiliation(s)
- Chanyoot Bandidwattanawong
- Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Thailand.
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Zeng H, Zhang F, Sun Y, Li S, Zhang W. Treatment options for neoadjuvant strategies of esophageal squamous cell carcinoma (Review). Mol Clin Oncol 2024; 20:4. [PMID: 38223404 PMCID: PMC10784769 DOI: 10.3892/mco.2023.2702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 10/26/2023] [Indexed: 01/16/2024] Open
Abstract
Compared with postoperative adjuvant therapy, neoadjuvant therapy has more potential advantages, such as decreasing tumor stage, killing micrometastatic cells. Because of these advantages, neoadjuvant therapy is recommended for numerous types of tumor, such as breast, lung and rectal cancer. To determine the role of neoadjuvant therapy on overall survival and adverse for patients with resectable esophageal carcinoma. we summarized clinical studies on 7 types of neoadjuvant therapies in this review. Currently, patients with esophageal cancer (EC) in China mainly receive postoperative treatment with <30% of patients receiving neoadjuvant therapy. One reason for the limited use of neoadjuvant therapy in China is inaccurate staging based on imaging and neoadjuvant treatment may increase difficulties in surgery. After neoadjuvant therapy, there may be tissue edema, blurry surgical field of view and unclear tissue gaps, resulting in greater difficulty in surgical procedures. However, oncologists are interested in neoadjuvant treatment, especially neoadjuvant immunotherapy to treat EC. Concurrent chemoradiotherapy for esophageal squamous cell carcinoma (ESCC) is the most common neoadjuvant treatment regimen and increases the pathological complete response (pCR) and 5- and 10-year survival rates. Preoperative induction chemotherapy and sequential concurrent chemoradiotherapy are currently the most widely treatments used in clinical practice in China. However, this treatment strategy does not yield long-term survival. The pCR rate of neoadjuvant immunotherapy is greater than that of concurrent chemoradiotherapy but, to the best of our knowledge, no evidence of long-term survival benefit has been found in phase I and II clinical trials. Neoadjuvant treatment should be considered for patients with locally advanced ESCC.
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Affiliation(s)
- Hai Zeng
- Department of Oncology, First Affiliated Hospital of Yangtze University, Jingzhou, Hubei 434000, P.R. China
| | - Fan Zhang
- Department of Oncology, First Affiliated Hospital of Yangtze University, Jingzhou, Hubei 434000, P.R. China
| | - Yujiao Sun
- Department of Clinical Medicine, Medical School of Yangtze University, Jingzhou, Hubei 434000, P.R. China
| | - Shuang Li
- Department of Oncology, First Affiliated Hospital of Yangtze University, Jingzhou, Hubei 434000, P.R. China
| | - Weijia Zhang
- Department of Oncology, First Affiliated Hospital of Yangtze University, Jingzhou, Hubei 434000, P.R. China
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Qi C, Hu L, Zhang C, Wang K, Qiu B, Yi J, Shen Y. Role of surgery in T4N0-3M0 esophageal cancer. World J Surg Oncol 2023; 21:369. [PMID: 38008742 PMCID: PMC10680323 DOI: 10.1186/s12957-023-03239-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/13/2023] [Indexed: 11/28/2023] Open
Abstract
BACKGROUND This study aimed to investigate an unsettled issue that whether T4 esophageal cancer could benefit from surgery. METHODS Patients with T4N0-3M0 esophageal cancer from 2004 to 2015 from the Surveillance, Epidemiology, and End Results (SEER) database were included in this study. Kaplan-Meier method, Cox proportional hazard regression, and propensity score matching (PSM) were used to compare overall survival (OS) between the surgery and no-surgery group. RESULTS A total of 1822 patients were analyzed. The multivariable Cox regression showed the HR (95% CI) for surgery vs. no surgery was 0.492 (0.427-0.567) (P < 0.001) in T4N0-3M0 cohort, 0.471 (0.354-0.627) (P < 0.001) in T4aN0-3M0 cohort, and 0.480 (0.335-0.689) (P < 0.001) in T4bN0-3M0 cohort. The HR (95% CI) for neoadjuvant therapy plus surgery vs. no surgery and surgery without neoadjuvant therapy vs. no surgery were 0.548 (0.461-0.650) (P < 0.001) and 0.464 (0.375-0.574) (P < 0.001), respectively. No significant OS difference was observed between neoadjuvant therapy plus surgery and surgery without neoadjuvant therapy: 0.966 (0.686-1.360) (P = 0.843). Subgroup analyses and PSM-adjusted analyses showed consistent results. CONCLUSION Surgery might bring OS improvement for T4N0-3M0 esophageal cancer patients, no matter in T4a disease or in T4b disease. Surgery with and without neoadjuvant therapy might both achieve better OS than no surgery.
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Affiliation(s)
- Chen Qi
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China
| | - Liwen Hu
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China
- Department of Cardiothoracic Surgery, Jinling Hospital, Jinling Clinical Medical School, Nanjing Medical University, Nanjing, 210002, China
| | - Chi Zhang
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China
| | - Kang Wang
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China
- Department of Cardiothoracic Surgery, Jinling Hospital, Jinling Clinical Medical School, Nanjing Medical University, Nanjing, 210002, China
| | - Bingmei Qiu
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China
- Department of Anesthesiology, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, 210004, China
| | - Jun Yi
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China.
- Department of Cardiothoracic Surgery, Jinling Hospital, Jinling Clinical Medical School, Nanjing Medical University, Nanjing, 210002, China.
| | - Yi Shen
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China.
- Department of Cardiothoracic Surgery, Jinling Hospital, Jinling Clinical Medical School, Nanjing Medical University, Nanjing, 210002, China.
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