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Survival after En Bloc Esophagectomy is Superior to Transhiatal Resection after Incomplete Response to Neoadjuvant Therapy
C. Rizzetto, C. G. Peyre, S. R. DeMeester, J. C. Lipham, J. A. Hagen, T. R. DeMeester. Keck School of Medicine, University of Southern California, Los Angeles, CA,
Objective: Neoadjuvant therapy is commonly used in patients with locally advanced esophageal adenocarcinoma. While complete pathologic response may indicate an improved prognosis, poor survival in patients with residual disease has prompted some to suggest that these patients not be considered for resection. We have reported improved survival in patients that undergo en bloc (EB) compared to transhiatal (TH) esophagectomy as primary therapy for esophageal adenocarcinoma. 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 esophagectomy from 1992-2005 were reviewed. Patients found to have systemic metastatic disease at operation or who had an incomplete resection were excluded.
Results: The study population consisted of 63 patients. The median age was 58 years. An en bloc resection was performed in 44 and a transhiatal resection in 19 patients. Operative mortality was similar (EB: 2/44 vs TH: 1/19, p=1.0). Final pathology revealed complete pathologic response to neoadjuvant therapy in 17/63 patients (27%). Median follow up was similar for both types of resection [EB: 27 months, TH: 16.3 months, p=0.22]. After en bloc resection, no patient had local recurrence compared to 3 patients (16.7%) after TH resection (p=0.024). Survival at 5 years in patients with complete pathologic response was similar for both types of resection (EB: 70%; TH: 53.6%, p=0.5). In contrast, 5 year survival in patients with residual disease after neoadjuvant therapy was significantly better after en bloc esophagectomy compared to transhiatal resection (41.3% vs 0%, p=0.037) [Figure]. All deaths in the transhiatal group were secondary to cancer. Among patients with residual disease after neoadjuvant therapy there were 3 patients alive at 5 years and considered cured of their cancer, and all had EB resection.
Conclusion: Contrary to the concept that surgery is not indicated in patients with residual disease after neoadjuvant therapy for esophageal adenocarcinoma, we demonstrate prolonged survival after resection in many patients. Further, in this setting the type of resection influences survival, and fit patients should undergo an en bloc rather than transhiatal esophagectomy.
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