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THE IMPACT OF NEOADJUVANT THERAPY ON OUTCOMES FOLLOWING ESOPHAGECTOMY FOR MALIGNANCY: A NSQIP ANALYSIS
Jahnavi Kakuturu*1, Ann-Kristin U. Friedrich1, Jason Wiseman1, Cameron Stock2, Giles F. Whalen1, Jennifer LaFemina1
1Surgery, University of Massachusetts Medical School , Worcester, MA; 2Thoracic Surgery, University of Massachusetts Medical School, Worcester, MA
BACKGROUND: Neoadjuvant therapy, in the form of radiation, chemotherapy or both, is commonly used in potentially resectable esophageal cancer. This study aims to determine the impact of neoadjuvant radiation, chemotherapy and chemoradiation on postoperative outcomes following esophagectomy for malignant indications.
METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients who underwent esophagectomy for malignancy from 2007-2012. The sample was categorized based on whether they received neoadjuvant chemoradiation, neoadjuvant radiation or chemotherapy alone, or no therapy. 30-day postoperative outcomes were compared.
RESULTS: Of 2991 patients, 417 (14%) received radiation alone, 119 (4%) chemotherapy alone, 253 (8%) chemoradiation, and 2202 (74%) no preoperative therapy. Patients given radiation only had higher incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE; 7% vs 4%, p<0.01 & 4% vs 2%, p=0.03, respectively) compared to those given no therapy. Multivariate analysis demonstrated an odds ratio of 1.9 for DVTs (95%CI 1.19-2.92, p<0.01) and 2.1 for PEs (95%CI 1.13-3.82, p=0.02). There was also a significantly lower blood transfusion rate in patients receiving radiation only compared to those receiving no therapy (8% vs 14%, OR 0.46, 95%CI 0.32-0.67, p<0.001). In the chemoradiation group, superficial surgical site infections (SSI) were more likely (12% vs 8%, OR 1.54, 95%CI 1.02-2.33, p=0.04) compared to the no therapy group. There was no difference in deep incisional or organ space SSI, suggesting equivalent anastomotic leak rates. There was also no difference in mortality or length of stay among groups.
CONCLUSIONS: In this national cohort undergoing esophagectomy for malignancy, neoadjuvant radiation alone was associated with higher incidence of DVTs and PEs and lower transfusion requirement. Neoadjuvant chemoradiation, currently the standard in the US, showed higher rate of superficial SSI. There was no difference in deep incisional or organ space infections with any treatment approach. Overall, these regimens appear safe with acceptable complication profiles.
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