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Esophagectomy Following Endoscopic Resection of Submucosal Esophageal Adenocarcinoma: A Highly Curative Procedure Even With Nodal Metastases
Daniela Molena*1, Joshua A. Boys2, Shanda H. Blackmon3, Karen J. Dickinson4, Christy M. Dunst5, Wayne L. Hofstetter6, Michal J. Lada7, Brian E. Louie8, Thomas J. Watson7, Steven R. DeMeester2
1Memorial Sloan Kettering Cancer Center, New York, NY; 2University of Southern California, Keck School of Medicine, Los Angeles, CA; 3Mayo Clinic, Rochester, MN; 4Methodist Hospital, Houston, TX; 5The Oregon Clinic, Portland, OR; 6MD Anderson, Houston, TX; 7University of Rochester Medical Center, Rochester, NY; 8Swedish Cancer Institute, Seattle, WA
Background: Optimal treatment for tumors extending into the sub-mucosa (T1b) is evolving in the era of endoscopic resection (ER). Despite the increased risk for nodal disease, definitive ER is being increasingly offered for lesions invasive into the submucosa (T1b) based on the success with intramucosal tumors. On the other hand, neo-adjuvant chemoradiation followed by esophagectomy is often advocated due to the notion that nodal disease portends a poor prognosis with esophagectomy alone. The aim of this study was to evaluate survival after esophagectomy alone for confirmed T1b tumors after ER.
Methods: Patients from seven centers in the United States who underwent esophagectomy for T1b tumors removed with ER. Tumor depth was confirmed by three experienced GI pathologist. Nodal involvement was correlated with recurrence and survival. Overall five-year survival was analyzed using the Kaplan-Meier method.
Results: We identified 23 patients with T1b esophageal adenocarcinoma. Esophagectomy was performed a median of 2 months (IQR 1-3) after the endoscopic resection. Ivor Lewis esophagectomy was done in 11 patients, 3-hole esophagectomy in 7, trans-hiatal approach in 4 and gastrectomy in 1 patient. A minimally invasive approach was used in 35% of cases. There was no post-operative mortality. Positive nodal disease was seen in 26% of patients on final pathology, with 5 patients having 1 and 1 patient with 3 positive nodes. At a median of 37 months (IQR 25-55) 91% of patients were alive and free of disease. One patient had systemic recurrence of disease 4 years after esophagectomy and died from his disease 9 months later. Another patient died from unrelated cause 7 years after esophagectomy. The disease-specific 5-year survival was 88%. Disease-specific 5-year survival was 67% in patients with positive nodal metastases and 100% in those without (p=0.197) (Figure).
Conclusions: Esophagectomy without chemoradiation therapy is curative in the majority of patients with submucosal tumors even in the presence of nodal metastases. These data serve as a benchmark for comparison when considering extending the indications for therapeutic ER for T1b tumors in the future.
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