Sex differences in survival following surgery for esophageal cancer: A systematic review and meta-analysis

The impact of sex on the prognosis of patients with esophageal cancer remains unclear. Evidence supports that sex- based disparities in esophageal cancer survival could be attributed to sex- specific risk exposures, such as age at diagnosis, race, socioeconomic status, smoking, drinking, and histological type. The aim of our study is to investigate the role of sex disparities in survival of patients who underwent surgery for esophageal cancer. A systematic review and meta-analysis of the existing literature in PubMed, EMBASE, and CENTRAL from December 1966 to February 2023, was held. Studies that reported sex-related differences in survival outcomes of patients who underwent esophagectomy for esophageal cancer were identified. A total of 314 studies were included in the quantitative analysis. Statistically significant results derived from 1-year and 2-year overall survival pooled analysis with Relative Risk (RR) 0.93 (95% Confidence Interval (CI): 0.90-0.97, I2 = 52.00) and 0.90 (95% CI: 0.85-0.95, I2 = 0.00), respectively (RR < 1 = favorable for men). In the postoperative complications analysis, statistically significant results concerned anastomotic leak and heart complications, RR: 1.08 (95% CI: 1.01-1.16) and 0.62 (95% CI: 0.52-0.75), respectively. Subgroup analysis was performed among studies with <200 and > 200 patients, histology types, study continent and publication year. Overall, sex tends to be an independent prognostic factor for esophageal carcinoma. However, unanimous results seem rather obscure when multivariable analysis and subgroup analysis occurred. More prospective studies and gender-specific protocols should be conducted to better understand the modifying role of sex in esophageal cancer prognosis.

Prognostication and optimal criteria of circumferential margin involvement for esophageal cancer after chemoradiation and esophagectomy

Purpose

Circumferential radial margin (CRM) involvement by tumor after resection for esophageal cancer has been suggested as a significant prognostic factor. However, the prognostic value of CRM involvement after surgery with neoadjuvant concurrent chemoradiotherapy (CCRT) is unclear. This study aimed to evaluate the prognostic value of and survival outcomes in CRM involvement as defined by the Royal College of Pathologists (RCP) and the College of American Pathologists (CAP) for patients with esophageal cancer undergoing neoadjuvant CCRT and esophagectomy.

Methods

A total of 299 patients with esophageal cancer who underwent neoadjuvant CCRT followed by esophagectomy between 2006 and 2016 were enrolled in our study. The CRM status of the specimens obtained was determined pathologically according to both the CAP and RCP criteria. Survival analyses were performed and compared according to the two criteria.

Results

Positive CRM was found in 102 (34.1%) and 40 (13.3%) patients according to RCP and CAP criteria, respectively. The overall and progression-free survival rates were significantly lower in the CRM-positive group than in the CRM-negative group according to both the RCP and CAP criteria. However, under multivariate analysis, in addition to pathological T and N staging of the tumor, only CAP-defined CRM positivity was a significant prognostic factor with adjusted hazard ratios of 2.64 (1.56-4.46) and 2.25 (1.34-3.78) for overall and progression-free survival, respectively (P < 0.001).

Conclusion

In patients with esophageal cancer undergoing neoadjuvant CRT followed by esophagectomy, CAP-defined CRM positivity is an independent predictor of survival. Adjuvant therapy should be offered to patients with positive CRM.

Prognostic impact of circumferential resection margin in esophageal cancer with or without neoadjuvant chemoradiotherapy

The prognostic impact of circumferential resection margin (CRM) in surgically resected esophageal squamous cell carcinoma (ESCC) has been controversial. This investigation assessed the prognostic impact of CRM in surgically resected pathologic T3 ESCC patients with or without neoadjuvant chemoradiotherapy (nCRT). We reviewed consecutive p/yp T3 ESCC patients undergoing esophagectomy from two medical centers between January 2009 and December 2016. The cohort was divided into two groups: upfront esophagectomy (upfront surgery) and nCRT followed by esophagectomy (nCRT + surgery). CRM status was assessed and divided into CRM > 1 mm, 0 < CRM < 1 mm, and tumor at CRM. A total of 217 p/yp T3 ESCC patients undergoing esophagectomy (138 patients in the upfront surgery group and 79 in the nCRT + surgery group) were enrolled. In the upfront surgery group, patients with 0 < CRM < 1 mm showed equivalent overall survival to those with CRM > 1 mm (log-rank P = 0.817) and significantly outlived those with tumor at CRM (log-rank P < 0.001). However, in the nCRT + surgery group, CRM > 1 mm failed to show survival superiority to CRM between 0 and 1 mm or involved by cancer (log-rank P = 0.390). In conclusion, a negative CRM, even though being <1 mm, is adequate for pT3 ESCC patients undergoing upfront esophagectomy. In contrast, the CRM status is less prognostic in ypT3 ESCC patients undergoing nCRT followed by esophagectomy.

Meta-analysis of the influence of a positive circumferential resection margin in oesophageal cancer

Background

The evidence regarding the prognostic impact of a positive circumferential resection margin (CRM) in oesophageal cancer is conflicting, and there is global variability in the definition of a positive CRM. The aim of this study was to determine the impact of a positive CRM on survival in patients undergoing oesophagectomy for oesophageal cancer.

Methods

A systematic review and meta‐analysis was performed. PubMed and Embase databases were searched for articles to May 2018 examining the effect of a positive CRM on survival. Cohort studies written in English were included. Meta‐analyses of univariable and multivariable hazard ratios (HRs) were performed using both Royal College of Pathologists (RCP) and College of American Pathologists (CAP) criteria. Risk of bias was assessed using the Newcastle–Ottawa Scale. Egger regression, and Duval and Tweedie trim‐and‐fill statistics were used to assess publication bias.

Results

Of 133 studies screened, 29 incorporating 6142 patients were finally included for analysis. Pooled univariable HRs for overall survival in patients with a positive CRM were 1·68 (95 per cent c.i. 1·48 to 1·91; P < 0·001) and 2·18 (1·84 to 2·60; P < 0·001) using RCP and CAP criteria respectively. Subgroup analyses demonstrated similar results for patients by T category, neoadjuvant therapy and tumour type. Pooled HRs from multivariable analyses suggested that a positive CRM was independently predictive of a worse overall survival (RCP: 1·41, 1·21 to 1·64, P < 0·001; CAP: 2·37, 1·60 to 3·51, P < 0·001).

Conclusion

A positive CRM is associated with a worse prognosis regardless of classification system, T category, tumour type or neoadjuvant therapy.

Prognostic significance of circumferential resection margin involvement in patients receiving potentially curative treatment for oesophageal cancer

INTRODUCTION

The utility of Circumferential Resection Margin (CRM) status in predicting prognosis in oesophageal cancer is controversial, with different definitions used by the College of American Pathologists and the Royal College of Pathologists. We aimed to determine prognostic significance of CRM involvement and evaluate which system is the best predictor of prognosis.

METHODS

A cohort of 390 patients who had potentially curative oesophagectomy (- + neoadjuvant chemotherapy) were analysed. Associations between CRM involvement and patient outcome were assessed for the whole cohort, and for pre-specified subgroups of T3 tumours and those who received neo-adjuvant chemotherapy.

RESULTS

CRM-involvement was associated with higher T and N stage, tumour differentiation, increased tumour length and both lymphovascular and perineural invasion. Overall Survival (OS) and Recurrence Free Survival (RFS) significantly worsened with CRM-involvement (p = 0.001, p < 0.001). R1a (<1 mm but no macroscopic involvement) resulted in significantly improved OS (p = 0.037) and RFS (P = 0.026) compared to R1b (macroscopic involvement), but did not differ significantly from R0 (≥1 mm). The association between CRM-involvement and both OS and RFS remained significant regardless of whether neoadjuvant chemotherapy was given. However, CRM-involvement was not a significant prognostic marker in T3 patients (p = 0.148). Multivariable analysis found N stage, lymphovascular invasion, patient age and neoadjuvant chemotherapy to be significantly predictive of patient outcome. CRM-involvement was not a significant independent prognostic marker.

CONCLUSIONS

CRM-involvement was not found to be independently predictive of prognosis, after accounting for other prognostic markers. As such, CRM should not be considered a major prognostic factor in patients with oesophageal cancer.

Impact of incremental circumferential resection margin distance on overall survival and recurrence in oesophageal adenocarcinoma

Background

Previous analyses of the oesophageal circumferential resection margin (CRM) have focused on the prognostic validity of two different definitions of a positive CRM, that of the College of American Pathologists (tumour at margin) and that of the Royal College of Pathologists (tumour within 1 mm). This study aimed to analyse the validity of these definitions and explore the risk of recurrence and survival with incremental tumour distances from the CRM.

Methods

This cohort study included patients who underwent resection for adenocarcinoma of the oesophagus between 2000 and 2014. Kaplan-Meier and Cox regression analyses were performed to determine the hazard ratio (HR) with 95 per cent confidence intervals for recurrence and mortality in CRM increments: tumour at the cut margin, extending to within 0·1-0·9, 1·0-1·9, 2·0-4·9 mm, and 5·0 mm or more from the margin.

Results

A total of 444 patients were included in the study. Kaplan-Meier and unadjusted analyses showed a significant incremental improvement in overall survival (P < 0·001) and recurrence (P for trend < 0·001) rates with increasing distance from the CRM. Tumour distance of 2·0 mm or more remained a significant predictor of survival on multivariable analysis (HR for risk of death 0·66, 95 per cent c.i. 0·44 to 1·00). Multivariable analysis of overall survival demonstrated a significant difference between a positive and negative CRM with the Royal College of Pathologists' definition (HR 1·37, 1·01 to 1·85), but not with the College of American Pathologists' definition (HR 1·22, 0·90 to 1·65).

Conclusion

This study demonstrated an incremental improvement in survival and recurrence rates with increasing tumour distance from the CRM.

Lymph Node Harvest During Esophagectomy Is Not Influenced by Use of Neoadjuvant Therapy or Clinical Disease Stage

INTRODUCTION

The purpose of this study was to evaluate the effects of neoadjuvant therapy on lymph node harvest (LNH), lymph node ratio (LNR), and overall survival rates after esophagectomy.

METHODS

A retrospective analysis of 111 patients who underwent esophagectomy for esophageal adenocarcinoma from 2001 to 2010 was performed. Patients were divided into two groups: neoadjuvant chemoradiotherapy prior to surgery (NEOSURG) versus surgery alone (SURG).

RESULTS

There were 83 patients (75%) in the NEOSURG group and 28 (25%) in the SURG group with a mean age of 66 and 67 years, respectively. The median LNH in the NEOSURG group and SURG group was 16.0 and 15.5, respectively (p = 0.57). Within the NEOSURG group, the median LNH was 16 for complete responders, 14 for partial responders, 16 for nonresponders, and 18 in those who were pathologically upstaged (p = 0.434). The median LNR was 0, 0, 0.1, and 0.2, respectively (p < 0.001). Complete response after neoadjuvant therapy demonstrated a trend toward improved survival (p = 0.056).

CONCLUSION

The LNH was not significantly influenced by neoadjuvant treatment or pathologic response. The LNR was inversely related to pathologic response after neoadjuvant therapy. Complete pathologic response to neoadjuvant therapy trends to improve survival rates.

Minimally invasive oesophagectomy in Wales

INTRODUCTION

The uptake of minimally invasive oesophagectomy remains low in the UK. As the only centre in Wales which offers this approach, our aim was to determine the short-term outcomes following endoscopic 2-stage oesophagectomy with stapled intra-thoracic anastomosis.

METHODS

Details of 50 consecutive patients [88% (44) male, median age (range) 66 (42-83) years] with operable mid to distal oesophageal and gastro-oesophageal junctional cancer who underwent endoscopic 2-stage oesophagectomy were analysed prospectively between June 2009 to November 2013. Primary outcome measures were overall and disease free survival from diagnosis. Secondary outcome measures were length of hospital stay, morbidity, mortality, lymph node harvest and margin involvement.

RESULTS

Median follow-up was 25 months. Seventy per cent (n = 35) of patients had stage II or greater disease and underwent neoadjuvant chemotherapy. The median length of hospital stay was 10 (range 8-104) days. There was a trend towards a decreasing length of stay as experience increased. Overall 30-day operative morbidity was 40% (n = 20) and there was no 30, 60, 90-day or in-patient mortality. Anastomotic leak occurred in 6 patients (12%). The median lymph node harvest was 20 (range 7-35) nodes. Nine patients (18%) had involvement of the circumferential resection margin (all T3). Overall and disease free 2-year survival was 84.2 and 80.9% respectively.

CONCLUSIONS

Endoscopic 2-stage oesophagectomy can be performed safely and effectively with good early oncological and surgical outcomes.

Radical lymphadenectomy in esophageal cancer: from the past to the present

Lymphadenectomy as an essential part of the surgical treatment has been one of the most controversial aspects in the management of esophageal cancers. The purpose of this article was to review the evolution, the current role, and the optimal extent of lymphadenectomy for the treatment of esophageal cancers. Studies discussing the outcome of esophagectomy with lymph nodes dissection and comparing among different extent of lymphadenectomy were used in the analysis. Several studies including recently published articles reveal that additional radical lymphadenectomy may be beneficial in some patients with non-extreme esophageal cancer undergoing esophagectomy, whereas two-field lymph node dissection is suitable for distal esophageal cancers regardless of the histology of the tumor. Minimally invasive surgery and neoadjuvant therapy combined with radical surgery seem to show more benefit in selected cases, but further studies should be required to clearly demonstrate their efficacy and safety. The expertise and experience of the surgeons should also be taken into account in determining the success of these radical procedures.

Longitudinal and circumferential resection margin in adenocarcinoma of distal esophagus and cardia

Multiple factors are implicated in the long-term survival of patients who have undergone esophagectomy, among these the involvement of longitudinal and circumferential resection margins are well known important prognostic factors. A few studies have assessed the impact of the operative approach on the status of the resection margins, and the data are not well reported, often unclear and, more importantly, there is no scientific evidence or published guideline on what the optimal proximal, distal or circumferential resection margin clearance should be. Owing to the lack of clarity on these points, we undertook a systematic literature review of the impact of longitudinal and circumferential resection margins in patients with operable esophageal cancer, the prognostic significance of margin involvement and the role of neoadjuvant therapy.

Investigation of the epithelial to mesenchymal transition markers S100A4, vimentin and Snail1 in gastroesophageal junction tumors

Epithelial to mesenchymal transition (EMT) promotes tumor progression and invasion. As no study has focused on gastroesophageal junction (GEJ) tumors, the expression of three EMT-related proteins (S100A4, vimentin, and Snail1) was investigated with the aim of assessing their pathologic and prognostic significance. Resection specimens were obtained from 104 patients who underwent surgery for GEJ adenocarcinoma, without preoperative chemotherapy. Three tissue cores were obtained from each of the tumor body (TB), luminal surface (LS), and invasive edge (IE) to produce tissue microarrays, and immunohistochemical staining was performed. The microarrays were scored independently by two observers. The demographic and histopathologic details of the patients were collected. Overall positive expression was observed in 88 (S100A4, 85%), 16 (vimentin, 14%), and 92 (Snail1, 89%) tumors. Staining for S100 A4 was positive in 79 (76%) of TB, 69 (66%) of IE, and 69 (66%) of LS specimens. Staining for vimentin was positive in 7 (6%) of TB, 11 (11%) of IE, and 5 (5%) of LS specimens. Staining for Snail1 was positive in 83 (80%) of TB, 51 (49%) of IE, and 78 (75%) of LS specimens. Positive staining of TB for S100A4 (P = 0.04) and Snail1 at IE (P = 0.01) was associated with involvement of circumferential resection margins. Positive staining for S100A4 in the TB (P = 0.02) and LS (P = 0.01) was associated with poor 5-year overall survival. Vimentin had no statistically significant relationships with pathologic factors or outcome. The acquisition of mesenchymal protein S100A4 is associated with a poor prognosis in patients with GEJ tumors who undergo potentially curative surgery, and LS samples can be used to obtain prognostic information. Increased EMT-related protein expression (S100A4, Snail1) is associated with the involvement of circumferential resection margin.

Prognostic significance of positive circumferential resection margin in esophageal cancer: a systematic review and meta-analysis

BACKGROUND

To assess the prognostic significance of positive circumferential resection margin on overall survival in patients with esophageal cancer, a systematic review and meta-analysis was performed.

METHODS

Studies were identified from PubMed, EMBASE, and Web of Science. Survival data were extracted from eligible studies to compare overall survival in patients with a positive circumferential resection margin with patients having a negative circumferential resection margin according to the Royal College of Pathologists (RCP) criteria and the College of American Pathologists (CAP) criteria. Survival data were pooled with hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs). A random-effects model meta-analysis on overall survival was performed.

RESULTS

The pooled HRs for survival were 1.510 (95% CI, 1.329-1.717; p<0.001) and 2.053 (95% CI, 1.597-2.638; p<0.001) according to the RCP and CAP criteria, respectively. Positive circumferential resection margin was associated with worse survival in patients with T3 stage disease according to the RCP (HR, 1.381; 95% CI, 1.028-1.584; p=0.001) and CAP (HR, 2.457; 95% CI, 1.902-3.175; p<0.001) criteria, respectively. Positive circumferential resection margin was associated with worse survival in patients receiving neoadjuvant therapy according to the RCP (HR, 1.676; 95% CI, 1.023-2.744; p=0.040) and CAP (HR, 1.847; 95% CI, 1.226-2.78; p=0.003) criteria, respectively.

CONCLUSIONS

Positive circumferential resection margin is associated with poor prognosis in patients with esophageal cancer, particularly in patients with T3 stage disease and patients receiving neoadjuvant therapy.

Venous invasion in oesophageal adenocarcinoma: enhanced detection using elastic stain and association with adverse histological features and clinical outcomes

AIMS

In oesophageal adenocarcinoma, detection rates of venous invasion using haematoxylin and eosin (H&E) and elastic stains have not been compared. The aims of this study were to investigate whether or not elastic stains facilitate the detection of venous invasion, and to determine the prognostic significance of venous invasion following review with elastic stains.

METHODS AND RESULTS

One hundred and three resection specimens containing oesophageal adenocarcinoma, all reported originally as negative for venous invasion, were examined for the presence of venous invasion using H&E and subsequently Movat pentachrome stains. Venous invasion was detected in eight cases with H&E and an additional 66 cases using Movat pentachrome; overall, 72% of cases contained venous invasion. Venous invasion was associated with advanced stage, tumour size, lymphatic and perineural invasion and subsequent distant metastases. Venous invasion, stage, size, grade, lymphatic invasion and perineural invasion were prognostically significant on univariate analysis. Only tumour stage was independently prognostic. Two of eight patients with venous invasion but no other indication for adjuvant treatment died of recurrent disease.

CONCLUSIONS

Elastic stains improve detection of venous invasion significantly in oesophageal adenocarcinoma. Venous invasion is associated with multiple adverse clinicopathological features. Its identification may facilitate the stratification of patients at risk for visceral metastases and disease-related death.

Recurrence risk after Ivor Lewis oesophagectomy for cancer

Objective

The aim of this study was to analyze the profile of tumor recurrence for patients operated on for cancer of oesophagogastric junction or oesophagus by Ivor-Lewis oesophagectomy.

Methods

Patients undergoing potentially curative Ivor-Lewis oesophageal resection between January 1999 to December 2008 at a single center institution were retrospectively analyzed. Their clinical records, details of surgical procedure, postoperative course, pathological findings, recurrence and long term survival were reviewed retrospectively. Univariate and multivariate survival analyses were performed.

Results

One hundred and twenty patients were analyzed. Fifty three patients (44%) presented recurrence during median follow-up of 58 months. Five-year relapse free survival (RFS) rate was 51% (95%CI = [46; 65%]). On multivariate analysis, pT stage > 2 (HR = 2.42, 95%CI = [1.22; 4.79] p = 0.011), positive lymph node status (HR = 3.69; 95% CI = [1.53; 8.96] p = 0.004) and lymph node ratio > 0.2 (HR = 2.57; 95%CI = [1.38; 4.76] p = 0.003) were associated with a poorer RFS and their combination was correlated to relapse risk. Moreover, preoperative tumor stenosis was associated with an increased risk of local recurrence (HR = 3.46; 95% CI = [1.38; 8.70] p = 0.008) whereas poor or undifferentiated tumor was associated with an increased risk of distant recurrence (HR = 3.32; 95% CI = [1.03; 10.04] p = 0.044).

Conclusion

pT stage > 2, positive lymph node status and lymph node ratio > 0.2 are independent prognostic factors of recurrence after Ivor-Lewis surgery for cancer. Their combination is correlated with an increasing risk of recurrence that may argue favorably, in addition with preoperative tumor stenosis assessment, for adjuvant treatment or reinforced follow-up.

Defining a positive circumferential resection margin in oesophageal cancer and its implications for adjuvant treatment

Background

A positive circumferential resection margin (CRM) has been associated with a poorer prognosis in oesophageal and oesophagogastric junctional (OGJ) cancer. The College of American Pathologists defines the CRM as positive if tumour cells are present at the margin, whereas the Royal College of Pathologists also include tumour cells within 1 mm of this margin. The relevance of these differences is not clear and no study has investigated the impact of adjuvant therapy. The aim was to identify the optimal definition of an involved CRM in patients undergoing resection for oesophageal or OGJ cancer, and to determine whether adjuvant radiotherapy improved survival in patients with an involved CRM.

Methods

This was a single-centre retrospective study of patients who had undergone attempted curative resection for a pathological T3 oesophageal or OGJ cancer. Clinicopathological variables and distance from the tumour to the CRM, measured to ± 0.1 mm, were correlated with survival.

Results

A total of 226 patients were included. Sex (P = 0·018), tumour differentiation (P = 0·019), lymph node status (P &lt; 0·001), number of positive nodes (P &lt; 0·001), and CRM distance (P = 0·042) were independently predictive of prognosis. No significant survival difference was observed between positive CRM 0-mm and 0·1–0·9-mm groups after controlling for other prognostic variables. Both groups had poorer survival than matched patients with a CRM at least 1 mm clear of tumour cells. Among patients with a positive CRM of less than 1 mm, those undergoing observation alone had a median survival of 18·6 months, whereas survival was a median of 10 months longer in patients undergoing adjuvant radiotherapy, but otherwise matched for prognostic variables (P = 0·009).

Conclusion

A positive CRM of 1 mm or less should be regarded as involved. Adjuvant radiotherapy confers a significant survival benefit in selected patients with an involved CRM.

Systematic review and meta-analysis of the influence of circumferential resection margin involvement on survival in patients with operable oesophageal cancer

Background

The prognostic role and definition of circumferential resection margin (CRM) involvement in operable oesophageal cancer remain controversial. The College of American Pathologists (CAP) and Royal College of Pathologists (RCP) define CRM involvement as tumour found at the cut resection margin and within 1 mm of the cut margin respectively. This systematic review and meta-analysis was performed to determine the influence of CRM involvement on survival in operable oesophageal cancer.

Methods

PubMed, MEDLINE and the Cochrane Library (January 1990 to June 2012) were searched for studies correlating CRM involvement with 5-year mortality. Statistical analysis of dichotomous variables was performed using the odds ratio (OR) as the summary statistic.

Results

Fourteen studies involving 2433 patients with oesophageal cancer who had undergone potentially curative oesophagectomy were analysed. Rates of CRM involvement were 15·3 per cent (173 of 1133) and 36·5 per cent (889 of 2433) according to the CAP and RCP criteria respectively. Overall 5-year mortality rates were significantly higher in patients with CRM involvement compared with CRM-negative patients according to both CAP (OR 4·02, 95 per cent confidence interval (c.i.) 2·25 to 7·20; P &lt; 0·001) and RCP (OR 2·52, 1·96 to 3·25; P &lt; 0·001) criteria. CRM involvement between 0·1 and 1 mm was associated with a significantly higher 5-year mortality rate than CRM-negative status (involvement more than 1 mm from CRM) (OR 2·05, 95 per cent c.i. 1·41 to 2·99; P &lt; 0·001).

Conclusion

CRM involvement is an important predictor of poor prognosis. CAP criteria differentiate a higher-risk group than RCP criteria, but overlook a patient group with similar poor outcomes.

Prognostic significance of circumferential resection margin involvement following oesophagectomy for cancer and the predictive role of endoluminal ultrasonography

Background:

The optimum multimodal treatment for oesophageal cancer, and the prognostic significance of histopathological tumour involvement of the circumferential resection margin (CRM+) are uncertain. The aims of this study were to determine the prognostic significance of CRM+ after oesophagectomy and to identify endosonographic (endoluminal ultrasonography (EUS)) features that predict a threatened CRM+.

Methods:

Two hundred and sixty-nine consecutive patients underwent potentially curative oesophagectomy (103 surgery alone, 124 neoadjuvant chemotherapy (CS) and 42 chemoradiotherapy (CRTS)). Primary outcome measures were disease-free survival (DFS) and overall survival (OS).

Results:

CRM+ was reported in 98 (38.0%) of all, and in 90 (62.5%) of pT3 patients. Multivariate analysis of pathological factors revealed: lymphovascular invasion (HR 2.087, 95% CI 1.396–3.122, P<0.0001), CRM+ (HR 1.762, 95% CI 1.201–2.586, P=0.004) and lymph node metastasis count (HR 1.563, 95% CI 1.018–2.400, P=0.041) to be independently and significantly associated with DFS. Lymphovascular invasion (HR 2.160, 95% CI 1.432–3.259, P<0.001) and CRM+ (HR 1.514, 95% CI 1.000–2.292, P=0.050) were also independently and significantly associated with OS. Multivariate analysis revealed EUS T stage (T3 or T4, OR 24.313, 95% CI 7.438–79.476, P<0.0001) and use or not of CRTS (OR 0.116, 95% CI 0.035–0.382, P<0.0001) were independently and significantly associated with CRM+.

Conclusion:

A positive CRM was a better predictor of DFS and OS than standard pTNM stage.

Neoadjuvant chemoradiotherapy followed by surgery for esophageal adenocarcinoma: significance of microscopically positive circumferential radial margins

OBJECTIVES

The incidence and consequence of an isolated involved circumferential radial margin (CRM) after resection for esophageal adenocarcinoma in the setting of neoadjuvant chemoradiotherapy (CRT) has not been reported. We aimed to determine the frequency and significance of a close (<1 mm) or involved CRM in patients undergoing esophagectomy after CRT.

METHODS

We retrospectively analyzed the data from patients undergoing resection from 1997 to 2008 for esophageal adenocarcinoma after neoadjuvant CRT. A positive CRM was defined as microscopic tumor at or less than 1 mm of the radial margin. An R1 resection was tumor at the radial margin. Only patients with ypT3 or greater tumors were included. R2 resections were excluded. Statistical comparisons were performed using Cox regression and Kaplan-Meier analyses.

RESULTS

A total of 160 patients met the inclusion criteria, 42 (26%) had a positive CRM. The median survival did not significantly differ between the CRM-negative and -positive groups (28 vs 50 months, P = .84). A propensity score matching analysis also failed to find a significant difference in outcomes. When analyzed by tumor present at the margin (R1), R0 patients had a longer median survival compared with R1 patients (28 vs 8 months, P = .01). This difference, however, was not seen on propensity score matching.

CONCLUSIONS

Resections of locally advanced esophageal adenocarcinoma with residual transmural viable tumor after CRT frequently showed involvement of the radial margin with tumor either close to or at the margin. Tumor close (<1 mm) to the radial margin did not result in a significant decrease in overall or disease-free survival or increase in local recurrence.

A critical appraisal of circumferential resection margins in esophageal carcinoma

Background

In esophageal cancer, circumferential resection margins (CRMs) are considered to be of relevant prognostic value, but a reliable definition of tumor-free CRM is still unclear. The aim of this study was to appraise the clinical prognostic value of microscopic CRM involvement and to determine the optimal limit of CRM.

Methods

To define the optimal tumor-free CRM we included 98 consecutive patients who underwent extended esophagectomy with microscopic tumor-free resection margins (R0) between 1997 and 2006. CRMs were measured in tenths of millimeters with inked lateral margins. Outcome of patients with CRM involvement was compared with a statistically comparable control group of 21 patients with microscopic positive resection margins (R1).

Results

A cutoff point of CRM at ≤1.0 mm and >1.0 mm appeared to be an adequate marker for survival and prognosis (both P < 0.001). The outcome in patients with CRMs ≤1.0 and >0 mm was equal to that in patients with CRM of 0 mm (P = 0.43). CRM involvement was an independent prognostic factor for both recurrent disease (P = 0.001) and survival (P < 0.001). Survival of patients with positive CRMs (≤1 mm) did not significantly differ from patients with an R1 resection (P = 0.12).

Conclusion

Involvement of the circumferential resection margins is an independent prognostic factor for recurrent disease and survival in esophageal cancer. The optimal limit for a positive CRM is ≤1 mm and for a free CRM is >1.0 mm. Patients with unfavorable CRM should be approached as patients with R1 resection with corresponding outcome.