OPTIMAL TREATMENT OF CT2N0 SQUAMOUS-CELLS ESOPHAGEAL CARCINOMA (SCC): IS UPFRONT SURGERY REALLY THE WAY?
Elisa Sefora Pierobon*, Giovanni Capovilla, Lucia Moletta, Gianpietro Zanchettin, Renato Salvador, Mario Costantini, Stefano Merigliano, Michele Valmasoni
University of Padova, Padova, Italy
Background
Multimodality treatment is the standard of care for locoregional thoracic esophageal squamous cell carcinoma (SCC), whereas the management of cT2N0 tumors is controversial. Current staging modalities are not accurate, and patients are often clinically under-staged or over-staged with different impact on their outcome.
Aim of the study was to evaluate the outcome of cT2N0-SCC who underwent esophagectomy as upfront treatment (Up-S) or after neoadjuvant therapy (CRT-S), considering the impact of clinical "mis-staging" on the outcome.
Methods
We retrospectively reviewed patients who underwent either upfront surgery (Up-S) or chemoradiotherapy followed by surgery (CRT-S) as the primary treatment for cT2N0-SCC.
Impact of neoadjuvant treatment in terms of 5-year OS, DFS, morbidity and mortality were evaluated.
We subsequently divided the Up-S patients in subgroups depending on the accuracy of the clinical staging according to the pathological report: (1) clinically under-staged (cUS), (2) over-staged (cOS) or (3) same-staged (cSS).
Appropriate statistical methods where performed to analyze and compare the groups.
Results
From 1990 to 2018 we selected 133 patients with cT2N0-SCC, 85% of which underwent Up-S. Five-year OS rates were 34.1 vs 46.2% (HR 1.57, p=0.04) in the Up-S and CRT-S groups, respectively. There was no significant difference in the disease-free survival between the two groups (HR 1.028, p=0.66). A radical resection was achieved in 98.5%, with no difference between the two groups (p=0.55). Morbidity and mortality rates were similar in the two groups.
In the Up-S group the cTNM was accurate in 23.9% (cSS), 18.6% were cOS and 57.5% were cUS; 46% had unexpected pathological nodal involvement. Subset analysis demonstrated a significantly reduced OS of cUS when compared with cSS (26% vs 40%, HR 1.96, p=0.008) and with cOS (26% vs 56%, HR 2.24, p=0.003). On multivariate analysis, tumor of the mid-lower esophagus and tumor length '‰¥3 cm at diagnosis resulted to be independent predictors of unexpected nodal metastases (OR 3.69, p=0.01 and OR 2.45, p=0.03, respectively).
Conclusions
The survival benefit when appropriately treating the cUS patients levels out the potentially futile treatment that cOS patients receive. Given the better 5-year OS of the CRT-S group with similar morbidity and mortality, we advocate to combine the induction therapy with surgery in cT2N0-SCC provided that, as for now, clinical staging tools are inadequate.
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