En bloc esophagectomy reduces local recurrence and improves survival compared with transhiatal resection after neoadjuvant therapy for esophageal adenocarcinoma

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 135; no. 6; pp. 1228 - 1236
• Main Authors: Rizzetto, C., MD, DeMeester, S.R., MD, Hagen, J.A., MD, Peyre, C.G., MD, Lipham, J.C., MD, DeMeester, T.R., MD
• Format: Journal Article
• Language: English
• Published: United States Mosby, Inc 01.06.2008; AATS/WTSA
• Subjects: Adenocarcinoma - drug therapy; Adenocarcinoma - mortality; Adenocarcinoma - pathology; Adenocarcinoma - surgery; Age Distribution; Aged; Antineoplastic Combined Chemotherapy Protocols - therapeutic use; Cardiothoracic Surgery; Cohort Studies; Diaphragm - surgery; Esophageal Neoplasms - drug therapy; Esophageal Neoplasms - mortality; Esophageal Neoplasms - pathology; Esophageal Neoplasms - surgery; Esophagectomy - methods; Esophagectomy - mortality; Female; Follow-Up Studies; Humans; Immunohistochemistry; Incidence; Kaplan-Meier Estimate; Male; Middle Aged; Neoadjuvant Therapy; Neoplasm Recurrence, Local - epidemiology; Neoplasm Recurrence, Local - pathology; Neoplasm Recurrence, Local - prevention & control; Neoplasm Staging; Postoperative Complications - mortality; Retrospective Studies; Risk Assessment; Sex Distribution; Survival Analysis; Thoracotomy - methods; Treatment Outcome; computed tomography; CT; positron emission tomography; PET; 7
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2007.10.082

Objective Neoadjuvant therapy is commonly used for esophageal adenocarcinoma. We have reported reduced local recurrence rates and improved survival after an en bloc esophagectomy compared with a transhiatal resection as primary therapy for adenocarcinoma of the esophagus. The aim of this study was to determine whether the benefits of an en bloc resection would extend to patients after neoadjuvant therapy. Methods The charts of all patients with esophageal adenocarcinoma that had neoadjuvant therapy and en bloc or transhiatal esophagectomy from 1992–2005 were reviewed. Patients found to have systemic metastatic disease at the time of the operation or who had an incomplete resection were excluded. Results There were 58 patients: 40 had an en bloc resection and 18 had a transhiatal esophagectomy. A complete pathologic response occurred in 17 (29.3%) of 58 patients. Median follow-up was 34.1 months after en bloc resection and 18.3 months after transhiatal resection ( P = .18). Overall survival at 5 years and survival in patients with residual disease after neoadjuvant therapy was significantly better with an en bloc resection (overall survival: 51% for en bloc resection and 22% for transhiatal resection [ P = .04]; survival with residual disease: 48% for en bloc resection and 9% for transhiatal resection [ P = .02]). Survival in patients with complete pathologic response tended to be better after an en bloc resection (en bloc, 70%; transhiatal, 43%; P = .3). Conclusion An en bloc resection provides a survival advantage to patients after neoadjuvant therapy compared with a transhiatal resection, particularly for those with residual disease. Similar to patients treated with primary resection, an en bloc esophagectomy is the procedure of choice after neoadjuvant therapy.