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Locally Advanced Esophageal Carcinoma Without Neoadjuvant Therapy: Is It Still Worth to Operate? a Single Institutional Experience
Matthias Reeh1, Michael F. Nentwich1, Asad Kutup1, Samir Asani1, Maximilian Bockhorn1, Guido Sauter2, Jakob R. Izbicki1, Dean Bogoevski*1
1General, Visceral and Thoracic Surgery, University Clinic Hamburg-Eppendorf, Hamburg, Germany; 2Institute of Pathology, University Clinic Hamburg-Eppendorf, Hamburg, Germany
Objective: To evaluate the impact of upfront surgery without neoadjuvant pre-treatment on survival in patients with clinically staged locally advanced esophageal canrcinoma. There is still controversy about whether neoadjuvant chemo or radio-chemotherapy should be the standard management in patients with locally advanced esophageal carcinoma. Furthermore, many gastroenterologists and oncologists believe that surgery should be avoided in locally advanced esophageal cancer due to high mortality and morbidity rates related to the procedure and the particularly low benefit for the patient.
Material and Methods: A retrospective analysis of prospectively collected data of patients with clinically advanced esophageal cancer (cT3) and without neo-adjuvant treatment who underwent thoraco-abdominal esophagectomy in curative intent. Locally advanced esophageal cancer was defined based on pre-surgical computertomography, endoscopy and endosonography findings as a tumor infiltrating the paraesophageal tissue or the adjacent structures, with or without lymph node affection.
Results: Histological subtypes included 131 squamous-cell carcinomas (SCC) and 81 adenocarcinomas (AC). Complete resection (R0) was achieved in 84.0% of all 212 patients. Thirty-day mortality rate was 7.1%. Final pathology revealed 50 patients (23.5%) with pT1 or pT2 carcinomas which were preoperatively overstaged. Median overall survival following TAE for SCC was 13.7 months (95% CI; 10.1-17.2 months) and 24.8 months (95% CI; 14.5-35.1 months) for AC, respectively (p= 0.007). The 5-year survival rates were 14% for SCC and 26% for AC, respectively. In median, 27 lymph nodes were resected. On multivariate analyses, histological type, tumor localization, a lymph node yield higher than 18 resected nodes, tumor grading and resection status remained independent factors influencing overall survival
Conclusion: Our results in the treatment of patients with locally advanced esophageal carcinoma undergoing primary TAE are comparable to the results reported for patients undergoing neoadjuvant chemo-radio-therapy followed by surgery (median 10 to 14 months; 5-YOS of 19-23%). Histological subtypes show different survival rates and should therefore be separately examined in future trials.
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