Zahoor Haris, Luketich James D, Levy Ryan M, Awais Omar, Winger Daniel G, Gibson Michael K, Nason Katie S
Department of Medicine, University of Pittsburgh, Pittsburgh, Pa.
Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa.
J Thorac Cardiovasc Surg. 2015 Feb;149(2):538-47. doi: 10.1016/j.jtcvs.2014.10.044. Epub 2014 Oct 14.
Prognosis for patients with locally advanced esophagogastric adenocarcinoma (EAC) is poor with surgery alone, and adjuvant therapy after open esophagectomy is frequently not tolerated. After minimally invasive esophagectomy (MIE); however, earlier return to normal function may render patients better able to receive adjuvant therapy. We examined whether primary MIE followed by adjuvant chemotherapy influenced survival compared with propensity-matched patients treated with neoadjuvant therapy.
Patients with stage II or higher EAC treated with MIE (N = 375) were identified. Using 30 pretreatment covariates, propensity for assignment to either neoadjuvant followed by MIE (n = 183; 54%) or MIE as primary therapy (n = 156; 46%) was calculated, generating 97 closely matched pairs. Hazard ratios were adjusted for age, sex, body mass index, smoking, comorbidity, and final pathologic stage.
In propensity-matched pairs, adjusted hazard ratio for death did not differ significantly for primary MIE compared with neoadjuvant (hazard ratio, 0.83; 95% confidence interval, 0.60-1.16). Recurrence patterns were similar between groups and 65% of patients with IIb or greater pathologic stage received adjuvant therapy. Clinical staging was inaccurate in 37 out of 105 patients (35%) who underwent primary MIE (n = 18 upstaged and n = 19 downstaged).
Primary MIE followed by adjuvant chemotherapy guided by pathologic findings did not negatively influence survival and allowed for accurate staging compared with clinical staging. Our data suggest that primary MIE in patients with resectable EAC may be a reasonable approach, improving stage-based prognostication and potentially minimizing overtreatment in patients with early stage disease through accurate stage assignments. A randomized controlled trial testing this hypothesis is needed.
局部晚期食管胃腺癌（EAC）患者单纯手术预后较差，开放食管切除术后辅助治疗常难以耐受。然而，微创食管切除术后（MIE），患者恢复正常功能的时间更早，可能使其更能耐受辅助治疗。我们比较了接受新辅助治疗的倾向评分匹配患者，探讨了原发性MIE后辅助化疗对生存率的影响。
确定375例接受MIE治疗的II期或更高分期EAC患者。利用30个治疗前协变量，计算接受新辅助治疗后MIE（n = 183；54%）或原发性MIE治疗（n = 156；46%）的分配倾向，生成97对紧密匹配的病例。对年龄、性别、体重指数、吸烟、合并症和最终病理分期进行危险比调整。
在倾向评分匹配的病例中，原发性MIE与新辅助治疗相比，调整后的死亡危险比无显著差异（危险比，0.83；95%置信区间，0.60 - 1.16）。两组间复发模式相似，65%的IIb期或更高病理分期患者接受了辅助治疗。105例接受原发性MIE的患者中有37例（35%）临床分期不准确（18例分期上调，19例分期下调）。
与临床分期相比，根据病理结果进行原发性MIE后辅助化疗对生存率无负面影响，且能实现准确分期。我们的数据表明可切除EAC患者原发性MIE可能是一种合理的方法，通过准确分期改善基于分期的预后，并可能减少早期疾病患者的过度治疗。需要进行一项随机对照试验来验证这一假设。
