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The Influence of Surgical Approach Methods in Different Interval Overall Survival: A Meta-Analysis of Preoperative Chemoradiotherapy Followed by Surgery With Surgery Alone in Resectable Esophageal Cancer
Yung-Han Sun*1,2, Shih-Wei Lin3,2, Chih-Cheng Hsieh1,3
1Division of Thoracic Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; 2Graduate Institute of Business and Management, Chang Gung University, Taoyuan, Taiwan; 3 Department of Information Management, Chang Gung University, Taipei, Taiwan
Background
Surgery and chemoradiotherapy are the main treatments for esophageal cancer. From systemic review, patients received preoperative chemoradiotherapy followed by surgery (CRT-S) had a better treatment outcome than those with surgical alone (SA). However, the results could be influenced by different surgical approach methods. In this study, we performed the meta-analysis based on randomized control trials (RCTs) to assess the different surgical approach methods impact on the results of CRT-S versus SA groups in different interval survival for esophageal cancer.
Material and Methods
We searched databases to regain possession of RCTs published between 1980 and 2014. Two investigators (Sun, Hsieh) independently reviewed titles, abstracts and full text of all citations identified by the literature search according to the PRISMA. The surgical approach methods for esophageal cancer are mainly transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE). The latter includes McKeown approach, Ivor-Lewis (Lewis-Tanner) approach and TTE without laparotomy. This meta-analysis was performed using Comprehensive meta-analysis (CMA) Version 2.0 software. The outcome variables were risk ratios (RRs) of 1, 3 & 5-year overall survival (OS) between CRT-S and SA groups.
Results
There were total of 2251 patients within these 15 RCTs, 1125 patients in the CRT-S group and 1126 patients treated with SA. The characteristics of enrolled studies are summarized in Table 1. The RRs of different interval OS in CRT-S group were significantly better than those with SA in resectable esophageal cancer. The RRs for 1-year, 3-year & 5-year were 0.869 (p=0.023), 0.874 (p <0.001) & 0.911 (p <0.001), respectively, showed in Figure 1. The surgical approach methods with Ivor-Lewis approach only in 2 RCTs, Ivor-Lewis and McKeown apporach in 3 RCTs and not mentioned in 3 studies did not influence the RR between CRT-S and SA groups. The RR of THE approach was significant lower in CRT-S group in short to middle-term OS (1-year RR: 0.292, p=0.001 & 3-year RR: 0.450, p <0.001). But, there was no 5-year OS data. Two studies with more than 3 surgical approach methods in surgery had a middle to long-term survival benefit in CRT-S group (3-year RR: 0.756, p <0.001 & 5-year RR 0.761, p <0.001), but not in 1-year. The only 1 study with combined approach methods of THE & TTE had a bizarre result. The 1-year (RR: 0.624, p =0.015) and 5-year (RR: 0.924, p =0.035) OS had a significant difference but not significant in 3-year OS.
Conclusions
In the study, surgical approach methods impacted the survival benefit between CRT-S and SA in different interval in patients with esophageal cancer. Different tumor location and histology in patients influenced the selection of different surgical approach methods may be the main cause resulting in survival difference.
 
Figure 1 The RR of 1, 3 and 5-year overall survival for CRT-S with SA in resectable esophageal cancer with different surgical approach methods.
Ivor-Lewis (Lewis-Tanner), abdominal-right thoracic approach; McKeown, right thoracic-abdominal-cervical approach; Mix, combined more than 3 approach methods; NA, not access; THE, transhiatal esophagectomy; TTE, transthoracic esophagectomy; CRT-S, preoperative chemoradiotherapy followed by surgery; SA, surgery alone.
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