Outcomes of patients with submucosal (T1b) esophageal adenocarcinoma: a multicenter cohort study

Otaki, Fouad; Gene, K.; Krigel, Anna; Dierkhising, Ross A.; Lewis, Jason T.; Blevins, Christopher H.; Gopalakrishnan, Naveen; Ravindran, Adharsh; Johnson, Michele L.; Leggett, Cadman L.; Wigle, Denis; Wang, Kenneth K.; Falk, Gary W.; Abrams, Julian A.; Nakagawa, Hiroshi; Rustgi, Anil K.; Wang, Yichen; Lightdale, Charles J.; Ginsberg, Gregory G.; Iyer, Prasad G.

doi:10.1016/j.gie.2020.01.013

Cited by 36 publications

(34 citation statements)

References 25 publications

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“…Hospitals must balance the consumption of resources potentially needed for COVID patients with the potential harm to cancer patients if operations are delayed. As survival from esophageal cancer precipitously decreases with stage progression [ 15 , 36 , 37 ], we created a simple and informative model to estimate the potential harm to a patient with an early stage cT1b esophageal adenocarcinoma if his care was delayed due to the COVID-19 pandemic.…”

Section: Discussionmentioning

confidence: 99%

Modeling the impact of delaying surgery for early esophageal cancer in the era of COVID-19

et al. 2020

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Background Surgical society guidelines have recommended changing the treatment strategy for early esophageal cancer during the novel coronavirus (COVID-19) pandemic. Delaying resection can allow for interim disease progression, but the impact of this delay on mortality is unknown. The COVID-19 infection rate at which immediate operative risk exceeds benefit is unknown. We sought to model immediate versus delayed surgical resection in a T1b esophageal adenocarcinoma. Methods A decision analysis model was developed, and sensitivity analyses performed. The base case was a 65-year-old male smoker presenting with cT1b esophageal adenocarcinoma scheduled for esophagectomy during the COVID-19 pandemic. We compared immediate surgical resection to delayed resection after 3 months. The likelihood of key outcomes was derived from the literature where available. The outcome was 5-year overall survival. Results Proceeding with immediate esophagectomy for the base case scenario resulted in slightly improved 5-year overall survival when compared to delaying surgery by 3 months (5-year overall survival 0.74 for immediate and 0.73 for delayed resection). In sensitivity analyses, a delayed approach became preferred when the probability of perioperative COVID-19 infection increased above 7%. Conclusions Immediate resection of early esophageal cancer during the COVID-19 pandemic did not decrease 5-year survival when compared to resection after 3 months for the base case scenario. However, as the risk of perioperative COVID-19 infection increases above 7%, a delayed approach has improved 5-year survival. This balance should be frequently re-examined by surgeons as infection risk changes in each hospital and community throughout the COVID-19 pandemic.

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Section: Discussionmentioning

confidence: 99%

Modeling the impact of delaying surgery for early esophageal cancer in the era of COVID-19

et al. 2020

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“…For short-term survival (in-hospital mortality), previous studies suggested that demographic factors [32], medical history [33], complications [34], and oncological characteristics [35] are associated with mortality rate of cancer patients. Thus, multivariable analysis of inhospital mortality adjusted for all the covariates in POAF analysis except preoperative HR and LVEF, and additionally adjusted for postoperative complications including pneumonia, anastomotic leak, sepsis, and acute kidney injury.…”

Section: Covariatesmentioning

confidence: 99%

The role of surgery type in postoperative atrial fibrillation and in-hospital mortality in esophageal cancer patients with preserved left ventricular ejection fraction

et al. 2020

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Background Postoperative atrial fibrillation (POAF) is one of the most common complications of esophagectomy, which may extend the inpatient hospital stay. Minimally invasive esophagectomy (MIE) has been increasingly used in clinical practice; however, its POAF risk and short-term mortality remain unclear. This study aimed to examine the POAF risk and in-hospital mortality rate between patients receiving MIE and open esophagectomy (OE). Methods Esophageal cancer patients who underwent MIE or OE from a retrospective cohort study were evaluated. A multivariate logistic regression model was built to assess the associations between esophagectomy (MIE vs. OE) and various outcomes (POAF, in-hospital mortality). Covariates included age, sex, body mass index, neoadjuvant therapy, tumor stage, surgery incision type, comorbidities, cardia conditions, peri-operative medication, and complications. Results Of the 484 patients with esophageal cancer, 63 received MIE. A total of 53 patients developed POAF. Compared to patients receiving OE, MIE patients had 81% reduced odds of POAF (adjusted odds ratio [aOR] 0.185, 95% CI 0.039–0.887, P = 0.035). No statistically significant association was found for in-hospital mortality (aOR 0.709, 95% CI 0.114–4.409, P = 0.712). Conclusions MIE is associated with a lower risk of POAF, compared to traditional surgery. No significant short-term survival benefit was found for MIE.

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“…15 Last, the authors report that 26% of the endoscopic therapy patients were treated with adjuvant chemotherapy or radiotherapy. However, 3-year and 5-year overall survival did not differ among patients with at least 1 high-risk histologic feature treated with endoscopic therapy alone compared with those treated with endoscopic therapy plus adjuvant chemotherapy/radiotherapy (Supplementary Table 3 12 ). Consequently, endoscopic therapy plus adjuvant chemotherapy/radiotherapy should not be considered a substitute for esophagectomy.…”

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confidence: 99%

“…In this issue of Gastrointestinal Endoscopy, 2 articles evaluate survival with endoscopic therapy versus esophagectomy for early-stage esophageal cancer. Otaki et al 12 retrospectively reviewed 141 patients with T1b submucosal adenocarcinoma from 3 academic centers in the United States. The primary outcome was overall survival.…”

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confidence: 99%

“…The 5year survival with esophagectomy in patients with at least 1 high-risk histologic feature was 85% compared with 28% in those receiving endoscopic therapy. Furthermore, Cox regression analysis showed that the predicted overall mor-tality in the presence of high-risk histologic features was very high with endoscopic therapy (Supplementary Table 2 12 ) but was 0.6 with surgery, indicating that esophagectomy is likely curative in patients with lymph node metastases or those at high risk for having node metastases and should be the preferred treatment strategy. The authors also report that esophagectomy was associated with a lower risk of cancer recurrence compared with endoscopic treatment (1.4 per 100 person years with esophagectomy compared with 6.7 per 100 person-years with endoscopic therapy).…”

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confidence: 99%

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When less is just less: endoscopic therapy for submucosal T1b esophageal cancer

Molena

DeMeester

2020

Gastrointestinal Endoscopy

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Outcomes of patients with submucosal (T1b) esophageal adenocarcinoma: a multicenter cohort study

Cited by 36 publications

References 25 publications

Modeling the impact of delaying surgery for early esophageal cancer in the era of COVID-19

Modeling the impact of delaying surgery for early esophageal cancer in the era of COVID-19

The role of surgery type in postoperative atrial fibrillation and in-hospital mortality in esophageal cancer patients with preserved left ventricular ejection fraction

When less is just less: endoscopic therapy for submucosal T1b esophageal cancer

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