Elsevier

Surgery

Volume 173, Issue 3, March 2023, Pages 693-701
Surgery

Foregut
The role of endoscopic resection in early-stage esophageal adenocarcinoma: Esophagectomy is associated with improved survival in patients presenting with clinical stage T1bN0 disease

Presented at the 79th annual meeting of the Central Surgical Association. 2–4 June, 2022 in Milwaukee, WI.
https://doi.org/10.1016/j.surg.2022.08.042Get rights and content

Abstract

Background

Studies evaluating endoscopic resection for early-stage (cT1N0M0) esophageal adenocarcinoma include small numbers of patients with T1b tumors. The role of endoscopic resection in esophageal adenocarcinoma remains incompletely defined.

Methods

We queried the National Cancer Database to identify patients presenting with esophageal adenocarcinoma between 2010 and 2017. Those treated with neoadjuvant chemoradiotherapy and endoscopic ablation were excluded. Patients undergoing endoscopic resection for cT1a and cT1b tumors were separately 1:1 propensity matched for relevant demographic and tumor factors to those undergoing esophagectomy for disease of like clinical stage. The Kaplan-Meier method was used to compare 5-year overall survival for matched cohorts.

Results

A total of 3,157 patients met the inclusion criteria. Of these patients, 2,024 (64.1%) had cT1a and 1133 (35.9%) had cT1b disease. Among those with cT1a tumors, 461 (22.8%) underwent esophagectomy, 1,357 (67.0%) endoscopic resection, and 206 (10.2%) treatment with chemoradiotherapy alone. Among those with cT1b tumors, 649 (57.3%) underwent esophagectomy, 293 (25.9%) endoscopic resection, and 191 (16.8%) chemoradiotherapy. On unadjusted comparison, patients treated for esophageal adenocarcinoma with chemoradiotherapy had a lower rate of overall survival than those treated with endoscopic resection or esophagectomy (26.1% vs 73.1% vs 75.5%, P < .001). On comparison of matched cohorts, patients undergoing endoscopic resection for cT1b tumors demonstrated lower rates of overall survival than those undergoing esophagectomy (60.6% vs 74.1%, P = .0013), whereas those undergoing endoscopic resection for cT1a tumors demonstrated rates of overall survival statistically similar to those undergoing esophagectomy (77.8% vs 80.2%, P = .75).

Conclusion

Esophagectomy is associated with improved overall survival relative to endoscopic resection in patients presenting with cT1bN0M0 but not in those with cT1a esophageal adenocarcinoma.

Introduction

Esophageal adenocarcinoma remains one of the most formidable malignant diseases treated. The Surveillance, Epidemiology, and End Results Program estimates that the 5-year overall survival (OS) for all patients presenting with esophageal cancer is 19.9%.1 The relatively poor prognosis is due primarily to the fact that a plurality of patients with esophageal cancer present with clinical evidence of distant metastasis (39%) or regional lymph node involvement (33%).1 Available systemic therapies continue to be of marginal benefit and, at such advanced stages, the disease is nearly uniformly lethal. This reality underscores 2 central needs in esophageal cancer care: effective early detection and effective management of early-stage esophageal cancer.

Esophagectomy has long been the established standard in the management of localized esophageal cancer. With contemporary postoperative mortality rates approaching 4% to 5% and postoperative morbidity rates in the range of 49.5% to 63.9%, esophagectomy is, however, among the most morbid operations done in the care of patients with cancer.2, 3, 4 Such persistently poor postoperative outcomes have led clinicians to develop and implement alternative treatment modalities. One such alternative, endoscopic resection (ER), has been increasingly used in patients presenting with early-stage disease (clinical stage T1N0M0).5

Prior studies evaluating the efficacy of ER compared with esophagectomy in early-stage esophageal cancer have been limited. Most have been single institutional series and have included a small number of patients presenting with T1b tumors. These studies have had mixed findings with some suggesting ER is on par with esophagectomy in providing durable survival benefit in early-stage cancers and others suggesting the opposite.6, 7, 8 More well-powered national cohort studies have generally excluded T1b tumors, have failed to adjust for key determinates of survival in their risk modeling, and have not compared outcomes of surgical and ER to the next best alternative treatment (chemoradiotherapy).5,9 For these reasons, the efficacy of endoscopic resection in patients presenting with early-stage (clinical stage T1N0M0) esophageal cancer remains incompletely defined. In the present study, we sought to evaluate OS outcomes associated with the use of esophagectomy, ER, and chemoradiotherapy (CRT) in the management of cT1aN0 and cT1bN0 staged esophageal adenocarcinoma (EAC).

Section snippets

Database and patient selection

The National Cancer Database (NCDB) includes >34 million patient records. These records represent >70% of all cancers diagnosed in the United States during those years.10 The NCDB includes hospital, treatment, tumor characteristics, and survival outcome variables, making it the most comprehensive clinical cancer registry in the world. The NCDB is made available by the American Cancer Society and the American College of Surgeons. As the database consists of deidentified patient level

Patient cohort

Between 2010 and 2017, 62,111 patients were registered in the NCDB as being diagnosed with esophageal adenocarcinoma. Of those, 4,586 patients presented with clinical stage cT1aN0 or cT1bN0 disease (Figure 1). After excluding unknown treatment, no treatment, adjuvant therapy, and neoadjuvant therapy, our final analytic dataset included 3,157 patients. Of these, 2,024 patients (64.1%) had cT1a and 1,133 patients (35.9%) had cT1b disease. Among those with cT1a tumors, 461 (22.8%) underwent

Discussion

The efficacy of endoscopic mucosal resection or endoscopic submucosal dissection relative to what has traditionally been considered the standard treatment of esophageal cancer—esophagectomy—has yet to be definitively determined. In the current study, we use 2 methods of time-to-event analysis to evaluate the OS of ER and esophagectomy in patients presenting with cT1aN0M0 or cT1bN0M0 esophageal adenocarcinoma. In both Cox proportional hazard and propensity matched Kaplan Meier models, patients

Funding/Support

This research did not receive any specific funding from any agencies in the public, commercial, or not-for-profit areas.

Conflict of interest/Disclosure

The authors have no conflicts of interests or disclosures to report.

Acknowledgments

The authors would like to point out that the American Cancer Society, American College of Surgeons, and Veterans Administration are not responsible for the conclusions presented in the current study.

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