Evolving progress in oncologic and operative outcomes for esophageal and junctional cancer: Lessons from the experience of a high-volume center

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 143; no. 5; pp. 1130 - 1137.e1
• Main Authors: Reynolds, John V., MD, Donohoe, Claire L., MB, McGillycuddy, Erin, MSc, Ravi, Naraymasamy, MD, O’Toole, Dermot, MD, O’Byrne, Ken, MD, Hollywood, Donal, MD
• Format: Journal Article
• Language: English
• Published: New York, NY Mosby, Inc 01.05.2012; Elsevier
• Subjects: Adenocarcinoma - mortality; Adenocarcinoma - pathology; Adenocarcinoma - therapy; Age Factors; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Carcinoma, Squamous Cell - mortality; Carcinoma, Squamous Cell - pathology; Carcinoma, Squamous Cell - therapy; Cardiology. Vascular system; Cardiothoracic Surgery; Chemoradiotherapy, Adjuvant; Chi-Square Distribution; Disease-Free Survival; Esophageal Neoplasms - mortality; Esophageal Neoplasms - pathology; Esophageal Neoplasms - therapy; Esophagectomy - adverse effects; Esophagectomy - mortality; Esophagogastric Junction - pathology; Esophagogastric Junction - surgery; Esophagus; Gastrectomy - adverse effects; Gastrectomy - mortality; Gastroenterology. Liver. Pancreas. Abdomen; Hospital Mortality; Hospitals - statistics & numerical data; Humans; Ireland; Kaplan-Meier Estimate; Lymph Node Excision; Medical sciences; Multivariate Analysis; Neoadjuvant Therapy; Neoplasm Invasiveness; Neoplasm Staging; Pneumology; Proportional Hazards Models; Prospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; Tumors; Ireland; computed tomography; CT; EUS; AEG; 7; TRG; adenocarcinoma of the esophagogastric junction; positron emission tomography; endoscopic ultrasound; tumor regression grade; PET; High; Center; Prognosis; Esophageal disease; Malignant tumor; Esophagus cancer; Experience; Treatment; Volume; Surgery; Digestive diseases; Anesthesia; Circulatory system; Cardiology; Cancer
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2011.12.003

Objective Modern series from high-volume esophageal centers report an approximate 40% 5-year survival in patients treated with curative intent and postoperative mortality rates of less than 4%. An objective analysis of factors that underpin current benchmarks within high-volume centers has not been performed. Methods Three time periods were studied, 1990 to 1998 (period 1), 1999 to 2003 (period 2), and 2004 to 2008 (period 3), in which 471, 254, and 342 patients, respectively, with esophageal cancer were treated with curative intent. All data were prospectively recorded, and staging, pathology, treatment, operative, and oncologic outcomes were compared. Results Five-year disease-specific survival was 28%, 35%, and 44%, and in-hospital postoperative mortality was 6.7%, 4.4%, and 1.7% for periods 1 to 3, respectively ( P  < .001). Period 3, compared with periods 1 and 2, respectively, was associated with significantly ( P  < .001) more early tumors (17% vs 4% and 6%), higher nodal yields (median 22 vs 11 and 18), and a higher R0 rate in surgically treated patients (81% vs 73% and 75%). The use of multimodal therapy increased ( P  < .05) across time periods. By multivariate analysis, age, T stage, N stage, vascular invasion, R status, and time period were significantly ( P  < .0001) associated with outcome. Conclusions Improved survival with localized esophageal cancer in the modern era may reflect an increase of early tumors and optimized staging. Important surgical and pathologic standards, including a higher R0 resection rate and nodal yields, and lower postoperative mortality, were also observed.