Voeten Daan M, den Bakker Chantal M, Heineman David J, Ket Johannes C F, Daams Freek, van der Peet Donald L
Department of Gastrointestinal Surgery, VU University Medical Center, De Boelelaan 1117, 7F020, 1081 HV, Amsterdam, The Netherlands.
Medical Library, Vrije Universiteit, Amsterdam, The Netherlands.
World J Surg. 2019 May;43(5):1271-1285. doi: 10.1007/s00268-018-04901-z.
Standard therapy for loco-regionally advanced, resectable oesophageal carcinoma is trimodality therapy (TMT) consisting of neoadjuvant chemoradiotherapy and oesophagectomy. Evidence of survival advantage of TMT over organ-preserving definitive chemoradiotherapy (dCRT) is inconclusive. The aim of this study is to compare survival between TMT and dCRT.
A systematic review and meta-analyses were conducted. Randomised controlled trials and observational studies on resectable, curatively treated, oesophageal carcinoma patients above 18 years were included. Three online databases were searched for studies comparing TMT with dCRT. Primary outcomes were 1-, 2-, 3- and 5-year overall survival rates. Risk of bias was assessed using the Cochrane risk of bias tools for RCTs and cohort studies. Quality of evidence was evaluated according to Grading of Recommendation Assessment, Development and Evaluation.
Thirty-two studies described in 35 articles were included in this systematic review, and 33 were included in the meta-analyses. Two-, three- and five-year overall survival was significantly lower in dCRT compared to TMT, with relative risks (RRs) of 0.69 (95% CI 0.57-0.83), 0.76 (95% CI 0.63-0.92) and 0.57 (95% CI 0.47-0.71), respectively. When only analysing studies with equal patient groups at baseline, no significant differences for 2-, 3- and 5-year overall survival were found with RRs of 0.83 (95% CI 0.62-1.10), 0.81 (95% CI 0.57-1.14) and 0.63 (95% CI 0.36-1.12).
These meta-analyses do not show clear survival advantage for TMT over dCRT. Only a non-significant trend towards better survival was seen, assuming comparable patient groups at baseline. Non-operative management of oesophageal carcinoma patients might be part of a personalised and tailored treatment approach in future. However, to date hard evidence proving its non-inferiority compared to operative management is lacking.
对于局部晚期、可切除的食管癌，标准治疗方法是三联疗法（TMT），包括新辅助放化疗和食管切除术。TMT相对于保留器官的根治性放化疗（dCRT）的生存优势证据尚无定论。本研究的目的是比较TMT和dCRT的生存率。
进行了系统评价和荟萃分析。纳入了对18岁以上可切除、接受根治性治疗的食管癌患者的随机对照试验和观察性研究。检索了三个在线数据库以查找比较TMT和dCRT的研究。主要结局是1年、2年、3年和5年总生存率。使用Cochrane偏倚风险工具对随机对照试验和队列研究评估偏倚风险。根据推荐评估、制定和评价分级对证据质量进行评估。
本系统评价纳入了35篇文章中描述的32项研究，荟萃分析纳入了33项研究。与TMT相比，dCRT的2年、3年和5年总生存率显著较低，相对风险（RR）分别为0.69（95%CI 0.57-0.83）、0.76（95%CI 0.63-0.92）和0.57（95%CI 0.47-0.71）。仅分析基线时患者组相等的研究时，2年、3年和5年总生存率无显著差异，RR分别为0.83（95%CI 0.62-1.10）、0.81（95%CI 0.57-1.14）和0.63（95%CI 0.36-1.12）。
这些荟萃分析未显示TMT相对于dCRT有明显的生存优势。假设基线时患者组具有可比性，仅观察到生存改善的非显著趋势。食管癌患者的非手术治疗可能是未来个性化和量身定制治疗方法的一部分。然而，迄今为止，缺乏确凿证据证明其与手术治疗相比不劣。
