En Bloc vs Transhiatal Esophagectomy for Stage T3 N1 Adenocarcinoma of the Distal Esophagus

Abstract

Hypothesis: En bloc esophagectomy (EBE) provides improved survival over transhiatal esophagectomy (THE) in patients with similarly sized transmural tumors (T3) and lymph node metastases (N1).Design: A retrospective case-control study of 2 methods of esophageal resection for cancer.Setting: University hospital (tertiary referral center for esophageal disease).Patients: There were 49 patients (27 who underwent EBE and 22 who underwent THE) with similar T3 N1 disease and the following matched criteria: tumors of similar size and location, more than 20 lymph nodes in the surgical specimen, R0 resection, no previous chemotherapy or radiation therapy, and follow-up until death or for a minimum of 5 years.Main Outcome Measure: Survival adjusted for dif-ferences in demographic and patient characteristics.Results: The number of nodes harvested was greatest after EBE vs THE (median, 52 vs 29 [range, 21-85 vs 20-60]; PϽ.001). The median number of involved nodes was similar after EBE vs THE (median, 5 vs 7 [range, 1-19 vs 1-16]). The only 2 independent factors that affected survival in a Cox analysis were the number of involved lymph nodes (P = .01) and the type of resection (P = .03). Patients who underwent EBE had a survival benefit over those who underwent THE (P =.01). The survival benefit of EBE was seen only in patients with fewer than 9 involved lymph nodes (PϽ.001). Conclusion:En bloc esophagectomy confers a better survival than THE in patients with T3 N1 disease and fewer than 9 lymph node metastases.

The role of lymphadenectomy in esophageal cancer

“…However, this benefit disappeared if >9 nodes were involved. This suggests that with increasing numbers of lymph node metastases the likelihood of distant metastatic disease is increased and hence more radical surgery is unlikely to provide any survival advantage [29].…”

Three-Gene Immunohistochemical Panel Adds to Clinical Staging Algorithms to Predict Prognosis for Patients With Esophageal Adenocarcinoma

“…3 This approach does not take into account the biology or molecular features of each individual tumor, which may explain the widely varying 5-year overall survival (OS), ranging from 11% to 41%, within groups of patients who otherwise seem similar by these standard staging algorithms. 4 It is increasingly evident that tremendous heterogeneity between patients exists in the biology underlying EAC; hence, the ideal staging system would take into account the biology and molecular features of each individual tumor and correlate prognosis with patient-specific tumor biomarkers. 5,6 Importantly, advancing knowledge of the molecular characteristics of the tumor would also enable the application of targeted therapies to improve selective killing of cancer cells.…”

Resultados De La Cirugía Actual Para El Tratamiento Del Cáncer De Esófago

“…Los tipos de esofaguectomía actualmente en uso son la esofaguectomía transhiatal, la misma técnica pero con preservación del vago ("vagal Sparing") y la esofaguectomía en block, que son técnicas poco difundidas y poco usadas. Actualmente las técnicas mini invasivas vía toracoscópica y laparoscópicas han ganado mucha difusión y muchos grandes centros de excelencia han adoptado esta técnica como la de elección [24][25][26] .…”

“…Al igual que en el punto anterior, a pesar de que hay estudios que muestran una mejor sobrevida con la cirugía en bloc (resección de grasa mediastínica posterior con los linfonodos, resección de conducto torácico, pericardio posterior, ambas pleuras, vena ácigos y membrana freno esofágica y parte del anillo hiatal) para los tumores del tercio inferior comparada con cirugía clásica más linfadenectomía en 2 campos total) 26,29 , la primera conlleva más horas quirúrgicas, más días de ventilación mecánica y más días de hospitalización 27 . no existe en este momento ningún centro en Chile con la experiencia suficiente (> 20 esofaguectomías al año) 40,41 , como para llevar a cabo esta técnica con baja mortalidad y el 91% de los cirujanos realizan la cirugía clásica.…”