Curative resection for esophageal adenocarcinoma: analysis of 100 en bloc esophagectomies

Abstract

Objective: To document what can be accomplished with surgical resection done according to the classical principles of surgical oncology.

Methods: One hundred consecutive patients underwent en bloc esophagectomy for esophageal adenocarcinoma. No patient received pre- or postoperative chemotherapy or radiation therapy. Tumor depth and number and location of involved lymph nodes were recorded. A lymph node ratio was calculated by dividing the number of involved nodes by the total number removed. Follow-up was complete in all patients. The median follow-up of surviving patients was 40 months, with 23 patients surviving 5 years or more.

Results: The overall actuarial survival rate at 5 years was 52%. Survival rates by American Joint Commission on Cancer (AJCC) stage were stage 1 (n = 26), 94%; stage 2a (n = 11), 65%; stage 2b (n = 13), 65%; stage 3 (n = 32), 23%; and stage 4 (n = 18), 27%. Sixteen tumors were confined to the mucosa, 16 to the submucosa, and 13 to the muscularis propria, and 55 were transmural. Tumor depth and the number and ratio of involved nodes were predictors of survival. Metastases to celiac (n = 16) or other distant node sites (n = 26) were not associated with decreased survival. Local recurrence was seen in only one patient. Latent nodal recurrence outside the surgical field occurred in 9 patients and systemic metastases in 31. Tumor depth, the number of involved nodes, and the lymph node ratio were important predictors of systemic recurrence. The surgical death rate was 6%.

Conclusion: Long-term survival from adenocarcinoma of the esophagus can be achieved in more than half the patients who undergo en bloc resection. One third of patients with lymph node involvement survived 5 years. Local control is excellent after en bloc resection. The extent of disease associated with tumors confined to the mucosa and submucosa provides justification for more limited and less morbid resections.

Figure 1. Actuarial survival, including surgical deaths, for the entire series.

Figure 2. Actuarial survival, including surgical deaths, according to the current American Joint Commission on Cancer staging classification system.

Figure 3. Actuarial survival, excluding surgical deaths, by tumor depth.

Figure 4. Actuarial survival, excluding surgical deaths, for patients with uninvolved nodes, one to four involved nodes, and more than four involved nodes.

Figure 5. Actuarial survival, excluding surgical deaths, according to lymph node ratio.

Figure 6. Time interval from initial surgery to treatment of latent nodal recurrence (dark bar) and outcome after treatment (light bar). †Death. OP, surgery; CT, chemotherapy; CRT, chemoradiotherapy; XRT, radiation therapy.