OUTCOMES OF ESOPHAGECTOMY FOR PATIENTS AFTER NON-CURATIVE ENDOSCOPIC RESECTION OF EARLY ESOPHAGEAL CANCER
Maximilien BarretSolène DermineMahaut LeconteSerge LeblancArthur BergerGabriel RahmiMathieu PiocheJM CanardVincent LépilliezOlivier PlomteuxFrédéric PratStanislas Chaussade
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Abstract:
To analyze the oncological outcomes and the safety of esophagectomy after non curative endoscopic resection of a superficial esophageal cancer.Keywords:
Esophagectomy
Endoscopic mucosal resection
Surgical resection
Esophagectomy
Chemoradiotherapy
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Objective To compare the long-term prognosis effects of non-esophagectomy and esophagectomy on patients with T1 stage esophageal cancer. Methods All esophageal cancer patients in the study were included from the National Surveillance Epidemiology and End Results (SEER) database between 2005-2015. These patients were classified into non-esophagectomy group and esophagectomy group according to therapy methods and were compared in terms of esophagus cancer specific survival (ECSS) and overall survival (OS) rates. Results A total of 591 patients with T1 stage esophageal cancer were enrolled in this study, including 212 non-esophagectomy patients and 111 esophagectomy patients in the T1a subgroup and 37 non-esophagectomy patients and 140 esophagectomy patients in the T1b subgroup. In all T1 stage esophageal cancer patients, there was no difference in the effect of non-esophagectomy and esophagectomy on postoperative OS, but postoperative ECSS in patients treated with non-esophagectomy was significantly better than those treated with esophagectomy. Cox proportional hazards regression model analysis showed that the risk factors affecting ECSS included race, primary site, tumor size, grade, and AJCC stage but factors affecting OS only include tumor size, grade, and AJCC stage in T1 stage patients. In the subgroup analysis, there was no difference in either ECSS or OS between the non-esophagectomy group and the esophagectomy group in T1a patients. However, in T1b patients, the OS after esophagectomy was considerably better than that of non-esophagectomy. Conclusions Non-esophagectomy, including a variety of non-invasive procedures, is a safe and available option for patients with T1a stage esophageal cancer. For some T1b esophageal cancer patients, esophagectomy cannot be replaced at present due to its diagnostic and therapeutic effect on lymph node metastasis.
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Postoperative complications, especially pulmonary complications, affect more than half the patients who undergo open esophagectomy for esophageal cancer. Whether hybrid minimally invasive esophagectomy results in lower morbidity than open esophagectomy is unclear.
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Since mucosal (T1a) esophageal cancer is well controlled by endoscopic treatment, chemoradiotherapy (CRTx) is not indicated. However, for a submucosal (T1b, N0) esophageal cancer, CRTx may be the first line of treatment, since it can provide a good response rate, with an excellent survival rate comparable to that after esophagectomy. Definitive CRTx is also in the first line of treatment for a T4 esophageal cancer, because there was no difference in the survival rate between CRTx with surgery and CRTx without surgery in our trial. Esophagectomy is indicated only for non-responders or recurrence-salvage surgery. For patients with a potentially-resectable (T2-T3) esophageal cancer, esophagectomy offered a longer survival rate than CRTx did, in our series. However, there remains controversy over the efficacy of CRTx for a T2-T3 esophageal cancer. It has been reported by the National Cancer Center Hospital East Group that definitive CRTx provided the same survival rate as esophagectomy. A prospective trial comparing the survival rate after esophagectomy and that after CRTx for a T2-T3 esophageal cancer is needed.
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Endoscopic resection is a standard treatment for stage T1a esophageal cancer, with esophagectomy or radical radiation therapy (RT) performed for stage T1b lesions. This study aimed to compare treatment outcomes of each modality for clinical stage T1 esophageal cancer.In total, 179 patients with clinical T1N0M0-stage esophageal cancer treated from 2006 to 2016 were retrospectively evaluated. Sixty-two patients with clinical T1a-stage cancer underwent endoscopic resection. Among 117 patients with clinical T1b-stage cancer, 82 underwent esophagectomy, and 35 received chemoradiotherapy or RT. We compared overall survival (OS) and recurrence-free survival (RFS) rates for each treatment modality.The median follow-up time was 32 months (range, 1 to 120 months). The 5-year OS and RFS rates for patients with stage T1a cancer receiving endoscopic resection were 100% and 85%, respectively. For patients with stage T1b, the 5-year OS and RFS rates were 78% and 77%, respectively, for the esophagectomy group; 80% and 44%, respectively, for the RT alone group; and 96% and 80%, respectively, for the chemoradiation group. The esophagectomy group showed significantly higher RFS than the RT alone group (p=0.04). There was no significant difference in RFS between the esophagectomy and chemoradiation groups (p=0.922). Grade 4 or higher treatment-related complications occurred in four patients who underwent esophagectomy.Endoscopic resection appeared to be an adequate treatment for patients with T1a-stage esophageal cancer. The multidisciplinary approach involving chemoradiation was comparable to esophagectomy in terms of survival outcome without serious complications for T1b-stage esophageal cancer.
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Background: Esophagectomy offers the chance of cure for esophageal cancer, however, the optimal circumferential extent of surgery remains uncertain. En bloc esophagectomy (EBE) and total meso-esophagectomy (TME) have yielded inconsistent results. Therefore, the purpose of this study was to evaluate the surgical and oncological effects of EBE and TME on esophageal cancer patients.
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Definitive chemoradiotherapy has been demonstrated to offer a chance of cure for esophageal cancer as often as a radical esophagectomy. However, it is generally accepted that an esophagectomy remains the mainstay of treatment for patients with resectable esophageal cancer, while chemoradiotherapy is the standard for patients with medically inoperable or surgically unresectable esophageal cancer. The mortality rates and the 5-year survival rates after an esophagectomy were 29% and 4%, respectively, in an early extensive reviews involving 122 English papers on esophageal cancer surgery published between 1960 and 1979. The respective rates have improved to 6.7% and 27.9% in the most recent systematic reviews involving 312 papers published between 1990 and 2000. The overall survival at 5 years was 36.1% after esophagectomy in 11,642 patients between 1988 and 1997 in Japan. A 3-field lymphadenectomy involving the 3 anatomical compartments of the neck, mediastinum, and abdomen was introduced as an important component of a curative esophageal resection in the early 1980s in Japan, and has been reported to be effective for improving not only the staging accuracy, but also the long-term survival in patients with esophageal cancer, with the average 5-year survival rate being 40 to 60%. At present, 63% of all Japanese patients with esophageal cancer undergo an esophagectomy. Of these patients undergoing surgery, a 3-field and a conventional 2-field lymphadenectomy is performed in 35% and 33%, respectively. Alternatively, a transhiatal esophagectomy without a systematic lymphadenectomy has become one of the preferred types of surgery for patients with esophageal cancer in Western countries. An Appropriate Esophagectomy for Esophageal Cancer: A Lack of Evidence and a Growing Disparity between Western and Eastern Standards
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