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Influence of Neoadjuvant Chemoradiation Therapy on Complications of Cervical Esophagogastric Anastomosis
Mian H. Hanif*1, Charles D. Goldman1, Sarah McAvoy2, George Voynov2, Christopher Young2, Jan Franko1
1Surgical Oncology, Mercy Medical Center, Des Moines, IA; 2Radiation Oncology, Mercy Cancer Center, Des Moines, IA
Background: The literature is inconsistent in regards to whether the use of chemoradiation prior to esophagectomy results in increased anastomotic complications. We examined the relationship of neoadjuvant chemoradiation to early and late anastomotic complications following esophagectomy.
Methods: Patients with distal esophageal and gastroesophageal junction cancers treated with neoadjuvant chemoradiation and subsequent esophagectomy with cervical anastomosis were included (n=37). Radiation dose was 50.4 Gy delivered in 28 fractions of 1.8 Gy. We calculated dose-volume parameters (mean, median, maximal dose, target volume receiving ≥ 20, 25, 30, 35, 40, 45, 50, 55 Gy) by contouring the gastric fundus and tip separately (Figure), and related it to anastomotic leak, stenosis and recalcitrant stenosis (RS≥3 dilations and/or stent).
Results: Patients with and without anastomotic complications had similar age, preoperative albumin level, rates of diabetes, and Charlson comorbidity index. There was a strong relationship between postoperative leak and recalcitrant stenosis (2 RS among 28 patients without leak vs. 4/9 among those with leak, p=0.022). A non-significant relation was observed between any stenosis and postoperative leak (5/28 vs. 4/9, p=0.078).
There was no association between radiation dose to gastric fundus or gastric tip and the occurrence of specified esophagectomy complications (leak, stenosis, RS; see Table). When comparing groups with and without specified complications, a near-significance was reached between RS and body height (174±9.0 vs. 169±10 cm; p=0.074), and proportion of gastric fundus receiving at least 55 Gy dose (V55) and leak (0.24% in no leak patients vs. 6.9% among those with leak; p=0.072).
Conclusions: In this study we identified no relationship between radiation dose delivered to gastric tip or fundus among patients undergoing neoadjuvant chemoradiation and subsequent esophagectomy complications. Modification of radiation therapy is unlikely to improve perioperative outcomes of esophagectomy.
Dose-volume data among patients with and without anastomotic complications
| | | Gastric Fundus | Gastric Tip | | | n | Mean
(Gy) | Max
(Gy) | D50
(Gy) | Vol
(cm3) | V20
(%) | V55
(%) | Mean
(Gy) | Max
(Gy) | D50
(%) | Vol
(cm3) | | Leak | | | | | | | | | | | | | absent | 28 | 3147 | 4994 | 3060 | 76±70 | 71.0 | 0.24 | 3009 | 4538 | 2997 | 16±11 | | present | 9 | 3464 | 5449 | 3268 | 67±33 | 82.4 | 6.96 | 3245 | 4927 | 2933 | 29±17 | | p value | | 0.745 | 0.465 | 0.776 | 0.871 | 0.369 | 0.072 | 0.807 | 0.168 | 0.745 | 0.168 | | Stenosis | | | | | | | | | | | | | absent | 29 | 3167 | 5035 | 3051 | 62±34 | 71.65 | 1.71 | 2968 | 4766 | 2868 | 18±10 | | present | 8 | 3369 | 5257 | 3314 | 136
±134 | 78.36 | 0 | 3439 | 3483 | 3543 | 21±23 | | p value | | 0.953 | 0.516 | 0.715 | 0.223 | 0.624 | 0.261 | 0.626 | 0.256 | 0.626 | 0.417 | Recalcitrant
stenosis | | | | | | | | | | | | | absent | 31 | 3259 | 5049 | 3158 | 59±35 | 73.07 | 1.62 | 3072 | 4793 | 2983 | 18±10 | | present | 6 | 2820 | 5242 | 2688 | 178
±127 | 71.15 | 0 | 2906 | 3356 | 2999 | 27±25 | | p value | | 0.411 | 0.465 | 0.615 | 0.017 | 0.783 | 0.343 | 0.784 | 0.100 | 0.784 | 0.927 |
p < 0. 05  Gastric Fundus as part of stomach superior to the Angle of His. Gastric Tip as the first 1 cm from the top
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