Division of General Thoracic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Tex.
Division of General Thoracic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Tex.
J Thorac Cardiovasc Surg. 2019 Apr;157(4):1682-1693.e1. doi: 10.1016/j.jtcvs.2018.11.131. Epub 2018 Dec 15.
To determine the association between neoadjuvant chemotherapy and chemoradiation therapy on completeness of pathologic response and to assess the impact of primary tumor versus nodal response on survival after esophagectomy.
Patients aged 18 to 80 years in the National Cancer Data Base (2006-2016) with clinically staged, locally advanced (cT2-4 or cN+) esophageal adenocarcinoma who underwent an R0 esophagectomy after neoadjuvant chemotherapy or chemoradiation therapy were included. Multivariable Cox proportional hazards regression models were constructed to assess the association between treatment response and survival.
Among 2870 patients, there was a significant dose-response association between completeness of response and overall survival: no response (reference), partial response (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.72-0.91), and complete response (HR, 0.55; 95% CI, 0.47-0.65). Compared with neoadjuvant chemotherapy alone, neoadjuvant chemoradiation was associated with higher pathologic primary tumor (33.9% vs 21.3%; P < .001) and pathologic nodal response rates (55.9% vs 32.7%; P < .001). Both a primary and nodal response were associated with improved survival. However, among patients with a primary but no nodal response, primary tumor response was not associated with risk of death (HR, 0.88; 95% CI, 0.69-1.11). In contrast, among patients who had a nodal but no primary response, the survival benefit of a nodal response was maintained (HR, 0.66; 95% CI, 0.58-0.76).
Pathologic nodal (rather than primary tumor) response to neoadjuvant therapy is associated with improved survival. These data suggest a need to optimize neoadjuvant strategies associated with more complete nodal response rates and to consider more aggressive adjuvant treatment for patients with residual nodal disease after esophagectomy.
确定新辅助化疗和放化疗对病理完全缓解的影响，并评估原发肿瘤与淋巴结反应对食管癌切除术后生存的影响。
本研究纳入了国家癌症数据库（2006-2016 年）中年龄在 18 至 80 岁之间、临床分期为局部晚期（cT2-4 或 cN+）的食管腺癌患者，这些患者在接受新辅助化疗或放化疗后进行了 R0 食管切除术。使用多变量 Cox 比例风险回归模型评估治疗反应与生存之间的关系。
在 2870 例患者中，反应的完全程度与总生存之间存在显著的剂量反应关系：无反应（参考）、部分反应（风险比[HR]，0.81；95%置信区间[CI]，0.72-0.91）和完全反应（HR，0.55；95%CI，0.47-0.65）。与单纯新辅助化疗相比，新辅助放化疗与更高的病理原发肿瘤（33.9%比 21.3%；P<.001）和病理淋巴结反应率（55.9%比 32.7%；P<.001）相关。原发肿瘤和淋巴结的反应都与生存改善相关。然而，在原发肿瘤有反应而淋巴结无反应的患者中，原发肿瘤反应与死亡风险无关（HR，0.88；95%CI，0.69-1.11）。相反，在淋巴结有反应而原发肿瘤无反应的患者中，淋巴结反应的生存获益得以维持（HR，0.66；95%CI，0.58-0.76）。
新辅助治疗的病理淋巴结（而非原发肿瘤）反应与生存改善相关。这些数据表明，需要优化与更高淋巴结完全缓解率相关的新辅助策略，并考虑对食管癌切除术后仍有淋巴结疾病的患者进行更积极的辅助治疗。
