Department of General, Visceral, Cancer, and Transplant Surgery, University Hospital of Cologne, Cologne, Germany.
Department of General, Visceral, and Transplant Surgery, University Hospital of Heidelberg, Heidelberg, Germany.
Ann Surg. 2023 Nov 1;278(5):683-691. doi: 10.1097/SLA.0000000000006011. Epub 2023 Jul 31.
The aim of this study was to explore oncologic outcomes of transhiatal gastrectomy (THG) or transthoracic esophagectomy (TTE) for neoadjuvantly treated gastroesophageal junction (GEJ) Siewert type II adenocarcinomas, a multinational, high-volume center cohort analysis was undertaken.
Neoadjuvant radiochemotherapy or perioperative chemotherapy (CTx) followed by surgery is the standard therapy for locally advanced GEJ. However, the optimal surgical approach for type II GEJ tumors remains unclear, as the decision is mainly based on individual experience and assessment of operative risk.
A retrospective analysis of 5 prospectively maintained databases was conducted. Between 2012 and 2021, 800 patients fulfilled inclusion criteria for type II GEJ tumors and neoadjuvant radiochemotherapy or CTx. The primary endpoint was median overall survival (mOS). Propensity score matching was performed to minimize selection bias.
Patients undergoing THG (n=163, 20.4%) had higher American Society of Anesthesiologists (ASA) classification and cT stage ( P <0.001) than patients undergoing TTE (n=637, 79.6%). Neoadjuvant therapy was different as the THG group were mainly undergoing CTx (87.1%, P <0.001). The TTE group showed higher tumor regression ( P =0.009), lower ypT/ypM categories (both P <0.001), higher nodal yield ( P =0.009) and higher R0 resection rate ( P =0.001). The mOS after TTE was longer (78.0 vs 40.0 months, P =0.013). After propensity score matching a higher R0 resection rate ( P =0.004) and mOS benefit after TTE remained ( P =0.04). Subgroup analyses of patients without distant metastasis ( P =0.037) and patients only after neoadjuvant chemotherapy ( P =0.021) confirmed the survival benefit of TTE. TTE was an independent predictor of longer survival.
Awaiting results of the randomized CARDIA trial, TTE should in high-volume centers be considered the preferred approach due to favorable oncologic outcomes.
本研究旨在探讨新辅助治疗食管胃交界部（GEJ）Siewert Ⅱ型腺癌患者行经胸食管切除术（TTE）或经食管裂孔胃切除术（THG）的肿瘤学结果。本研究为一项多中心、大样本量的队列分析。
新辅助放化疗或围手术期化疗（CTx）后手术是局部晚期 GEJ 的标准治疗方法。然而，对于 II 型 GEJ 肿瘤的最佳手术方法仍不清楚，因为该决定主要基于个人经验和手术风险评估。
对 5 个前瞻性维护的数据库进行回顾性分析。2012 年至 2021 年期间，800 例符合 II 型 GEJ 肿瘤和新辅助放化疗或 CTx 标准的患者纳入本研究。主要终点是中位总生存期（mOS）。采用倾向性评分匹配来最小化选择偏倚。
行 THG（n=163，20.4%）的患者 ASA 分级和 cT 分期高于行 TTE（n=637，79.6%）（P<0.001）。新辅助治疗也有所不同，因为 THG 组主要接受 CTx（87.1%，P<0.001）。TTE 组的肿瘤退缩程度更高（P=0.009），ypT/ypM 分期更低（均 P<0.001），淋巴结检出数更多（P=0.009），R0 切除率更高（P=0.001）。TTE 后的 mOS 更长（78.0 个月 vs 40.0 个月，P=0.013）。经过倾向性评分匹配后，TTE 组的 R0 切除率更高（P=0.004），且 mOS 获益仍有统计学意义（P=0.04）。在无远处转移的患者亚组（P=0.037）和仅接受新辅助化疗的患者亚组（P=0.021）中，TTE 也证实了生存获益。TTE 是生存时间延长的独立预测因素。
在 CARDIA 试验的结果公布之前，由于 TTE 具有良好的肿瘤学结果，在高容量中心，TTE 应被视为首选方法。
