Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institute, and Esophageal and Gastric Cancer Unit, Karolinska University Hospital, Stockholm, Sweden.
Department of Oncology, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden.
Dis Esophagus. 2020 May 15;33(5). doi: 10.1093/dote/doz078.
The optimal time interval from neoadjuvant therapy to surgery in the treatment of esophageal cancer is not known. The aim of this study was to investigate if a prolonged interval between completed neoadjuvant chemoradiotherapy and surgery was associated with improved histological response rates and survival in a population-based national register cohort. The population-based cohort study included patients treated with neoadjuvant chemoradiotherapy and esophagectomy due to cancer in the esophagus or gastroesophageal junction. Patients were divided into two groups based on the median time from completed neoadjuvant treatment to surgery. The primary outcome was complete histological response. Secondary outcomes were lymph node tumor response, postoperative complications, R0 resection rate, 90-day mortality, and overall survival. In total, 643 patients were included, 344 (54%) patients underwent surgery within 49 days, and 299 (47%) after 50 days or longer. The groups were similar concerning baseline characteristics except for a higher clinical tumor stage (P = 0.009) in the prolonged time to surgery group. There were no significant differences in complete histological response, R0 resection rate, postoperative complications, 90-day mortality, or overall survival. Adjusted odds ratio for ypT0 in the prolonged time to surgery group was 0.99 (95% confidence interval: 0.64-1.53). Complete histological response in the primary tumor (ypT0) was associated with significantly higher overall survival: adjusted hazard ratio: 0.55 (95% CI 0.41-0.76). If lymph node metastases were present in these patients, the survival was, however, significantly lower: adjusted hazard ratio for ypT0N1: 2.30 (95% CI 1.21-4.35). In this prospectively collected, nationwide cohort study of esophageal and junctional type 1 and 2 cancer patients, there were no associations between time to surgery and histological complete response, postoperative outcomes, or overall survival. The results suggest that it is safe for patients to postpone surgery at least 7 to 10 weeks after completed chemoradiotherapy, but no evidence was seen in favor of recommending a prolonged time to surgery after neoadjuvant chemoradiotherapy for esophageal cancer. A definitive answer to this question requires a randomized controlled trial of standard vs. prolonged time to surgery.
新辅助放化疗后至手术的最佳时间间隔尚不清楚。本研究旨在探讨完成新辅助放化疗后至手术的时间间隔延长是否与人群基础登记队列中患者的组织学反应率和生存改善相关。该基于人群的队列研究纳入了因食管癌或食管胃交界部癌接受新辅助放化疗和食管切除术的患者。根据完成新辅助治疗至手术的中位时间，将患者分为两组。主要结局为完全组织学缓解。次要结局为淋巴结肿瘤反应、术后并发症、R0 切除率、90 天死亡率和总生存率。共纳入 643 例患者，其中 344 例（54%）患者在 49 天内行手术，299 例（47%）患者在 50 天或更长时间内行手术。两组患者在基线特征方面无显著差异，但在手术时间延长组中临床肿瘤分期较高（P = 0.009）。完全组织学缓解、R0 切除率、术后并发症、90 天死亡率和总生存率无显著差异。手术时间延长组 ypT0 的调整后比值比为 0.99（95%置信区间：0.64-1.53）。原发肿瘤完全组织学缓解（ypT0）与总生存率显著升高相关：调整后的危险比为 0.55（95%可信区间 0.41-0.76）。如果这些患者存在淋巴结转移，则生存显著降低：ypT0N1 的调整后危险比为 2.30（95%可信区间 1.21-4.35）。在这项前瞻性收集的食管和交界性 1 型和 2 型癌症患者的全国性队列研究中，手术时间与组织学完全缓解、术后结局或总生存率之间无关联。结果表明，患者在完成放化疗后至少 7-10 周推迟手术是安全的，但没有证据支持为新辅助放化疗后的食管癌推荐延长手术时间。这一问题的明确答案需要标准 vs. 延长手术时间的随机对照试验。
