Histologic tumor type is an independent prognostic parameter in esophageal cancer: lessons from more than 1,000 consecutive resections at a single center in the Western world

Abstract

Objective: To analyze the changing pattern in tumor type and postoperative deaths at a national referral center for esophageal cancer in the Western world and to assess prognostic factors for long-term survival after resection.

Summary background data: During the past two decades, the epidemiology and treatment strategies of esophageal cancer have changed markedly in the Western world. The influence of these factors on postoperative deaths and long-term prognosis has not been adequately evaluated.

Methods: Between 1982 and 2000, 1,059 patients with primary esophageal squamous cell cancer or adenocarcinoma had resection with curative intention at a single center. Patient and tumor characteristics and details of the surgical procedure and outcome were documented during this period. Follow-up was available for 95.8% of the patients. Changing patterns in tumor type and postoperative deaths were analyzed. Prognostic factors for long-term survival were assessed by multivariate analysis.

Results: The prevalence of adenocarcinoma in patients with resected esophageal cancer increased markedly during the study period. The postoperative death rate decreased from about 10% before 1990 to less than 2% since 1994, coinciding with the introduction of a procedure-specific composite risk score and exclusion of high-risk patients from surgical resection. In addition to the well-established prognostic parameters, tumor cell type "adenocarcinoma" was identified as a favorable independent predictor of long-term survival after resection. The independent prognostic effect of tumor cell type persisted in the subgroups of patients with primary resection and patients with primary resection and R0 category.

Conclusion: Esophagectomy for esophageal cancer has become a safe procedure in experienced hands. Esophageal adenocarcinoma has a better long-term prognosis after resection than squamous cell carcinoma.

Figure 1. Increasing prevalence of adenocarcinoma among patients with resected esophageal cancer.

Figure 2. Increasing use of neoadjuvant chemotherapy or combined radiochemotherapy in patients who underwent resection for esophageal cancer during the study period.

Figure 3. Decrease in the postoperative death rate after esophagectomy for esophageal cancer during the study period.

Figure 4. Overall 10-year survival curve of patients with resected adenocarcinoma (n = 407) versus patients with resected squamous cell carcinoma of the esophagus (n = 652).

Figure 5. Ten-year survival curve of patients with adenocarcinoma (n = 253) versus patients with resected squamous cell carcinoma of the esophagus (n = 323). Only patients with primary resection and complete macroscopic and microscopic tumor removal (R0 resection) are included.

Figure 6. Ten-year survival curve of patients with adenocarcinoma (n = 137) versus patients with resected squamous cell carcinoma of the esophagus (n = 160). Only patients with primary resection, complete macroscopic and microscopic tumor removal (R0 category), and N0 category are included.