Division of Cardiothoracic Surgery, Washington University, St Louis, Mo.
Division of Surgical Oncology, Department of Surgery, Washington University, St Louis, Mo.
J Thorac Cardiovasc Surg. 2018 May;155(5):2221-2230.e1. doi: 10.1016/j.jtcvs.2018.01.006. Epub 2018 Jan 12.
We compared the effectiveness of upfront esophagectomy versus induction chemoradiation followed by esophagectomy for overall survival in patients with clinical T2N0 (cT2N0) esophageal cancer. We also assessed the influence of the diagnostic uncertainty of endoscopic ultrasound on the expected benefit of chemoradiation.
We created a decision analysis model representing 2 treatment strategies for cT2N0 esophageal cancer: upfront esophagectomy that may be followed by adjuvant therapy for upstaged patients and induction chemoradiation for all patients with cT2N0 esophageal cancer followed by esophagectomy. Parameter values within the model were obtained from published data, and median survival for pathologic subgroups was derived from the National Cancer Database. In sensitivity analyses, staging uncertainty of endoscopic ultrasound was introduced by varying the probability of pathologic upstaging.
The baseline model showed comparable median survival for both strategies: 48.3 months for upfront esophagectomy versus 45.9 months for induction chemoradiation and surgery. The sensitivity analysis demonstrated induction chemoradiation was beneficial, with probability of upstaging > 48.1%, which is within the published range of 32% to 65% probability of pathologic upstaging after cT2N0 diagnosis. The presence of any of 3 key variables (size larger than 3 cm, high grade, or lymphovascular invasion) was associated with > 48.1% risk of upstaging, thus conferring a survival advantage to induction chemoradiation.
The optimal treatment strategy for cT2N0 esophageal cancer depends on the accuracy of endoscopic ultrasound staging. High-risk features that confer increased probability of upstaging can inform clinical decision making to recommend induction chemoradiation for select cT2N0 patients.
我们比较了临床 T2N0（cT2N0）食管癌患者中直接手术与诱导放化疗后手术治疗总生存率的效果。我们还评估了内镜超声检查诊断不确定性对放化疗预期获益的影响。
我们建立了一个决策分析模型，代表了两种治疗 cT2N0 食管癌的策略：直接手术，可能对分期升级的患者进行辅助治疗，以及所有 cT2N0 食管癌患者进行诱导放化疗，然后进行手术。模型内的参数值来自已发表的数据，病理亚组的中位生存时间来自国家癌症数据库。在敏感性分析中，通过改变病理升级的概率引入了内镜超声检查的分期不确定性。
基线模型显示两种策略的中位生存时间相当：直接手术为 48.3 个月，诱导放化疗和手术为 45.9 个月。敏感性分析表明，诱导放化疗是有益的，分期升级的概率>48.1%，这在已发表的 cT2N0 诊断后病理升级概率为 32%至 65%的范围内。存在 3 个关键变量（大小大于 3cm、高级别或血管淋巴管侵犯）中的任何一个，与>48.1%的分期升级风险相关，从而为诱导放化疗带来生存优势。
cT2N0 食管癌的最佳治疗策略取决于内镜超声检查分期的准确性。具有增加分期升级概率的高危特征可以为临床决策提供信息，建议对某些 cT2N0 患者进行诱导放化疗。
