Raja Siva, Rice Thomas W, Lu Min, Semple Marie E, Toth Andrew J, Blackstone Eugene H, Murthy Sudish C, Ahmad Usman, McNamara Michael, Ishwaran Hemant
From the Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH.
Division of Biostatistics, Department of Public Health Sciences, University of Miami, Miami, FL.
Ann Surg Open. 2024 Oct 15;5(4):e497. doi: 10.1097/AS9.0000000000000497. eCollection 2024 Dec.
Based on current practice guidelines, we hypothesized that most patients with esophageal cancer, particularly those with locally advanced cancer, would benefit from adjuvant therapy after esophagectomy esophagectomy alone. We sought to obtain a granular estimate of patient-level risk-adjusted survival for each therapeutic option by cancer histopathology and stage.
Although esophagectomy alone is now an uncommon therapy for treating locally advanced esophageal cancer, the value of adjuvant therapy after esophagectomy is unknown.
From 1970 to 2014, 22,123 consecutive patients from 33 centers on 6 continents (Worldwide Esophageal Cancer Collaboration) were diagnosed with biopsy-proven adenocarcinoma (n = 7526) or squamous cell carcinoma (n = 5625), of whom 10,873 received esophagectomy alone and 2278 additional adjuvant therapy. Random forests for survival and virtual-twin analyses were performed for all-cause mortality.
For adenocarcinoma, adjuvant therapy was beneficial only in pT4NanyM0 cancers (6-8 month survival benefit) and in pTanyN3M0 cancers (4-8 month benefit); a survival decrement was observed in pT1-3N0M0 cancers, with no effect on TanyN1-2M0 cancers. In squamous cell carcinoma, there was a 4 to 21 month survival benefit for pT3-4N0M0 cancers and a 4 to 15 month survival benefit for pT2-4N1-3M0 cancers.
Adjuvant therapy after esophagectomy appears to benefit most patients with node-positive squamous cell carcinoma, but for adenocarcinoma, its value is limited to deep cancers and to those with substantial nodal burden. Future studies of the role of adjuvant therapies should treat these 2 cancers differently, with guidelines reflecting the histopathologic-appropriate survival value of adjuvant therapy.
基于当前的实践指南，我们推测大多数食管癌患者，尤其是局部晚期癌症患者，在食管切除术后接受辅助治疗会比单纯接受食管切除术更有益。我们试图通过癌症组织病理学和分期，对每种治疗方案的患者水平风险调整生存率进行精确估计。
尽管单纯食管切除术目前已不是治疗局部晚期食管癌的常用方法，但食管切除术后辅助治疗的价值尚不清楚。
1970年至2014年，来自六大洲33个中心的22123例连续患者（全球食管癌协作组）经活检证实患有腺癌（n = 7526）或鳞状细胞癌（n = 5625），其中10873例仅接受了食管切除术，另外2278例接受了辅助治疗。对全因死亡率进行了生存随机森林分析和虚拟孪生分析。
对于腺癌，辅助治疗仅对pT4NanyM0癌症（生存获益6 - 8个月）和pTanyN3M0癌症（生存获益4 - 8个月）有益；在pT1 - 3N0M0癌症中观察到生存下降，对TanyN1 - 2M0癌症无影响。在鳞状细胞癌中，pT3 - 4N0M0癌症有4至21个月的生存获益，pT2 - 4N1 - 3M0癌症有4至15个月的生存获益。
食管切除术后辅助治疗似乎对大多数淋巴结阳性鳞状细胞癌患者有益，但对于腺癌，其价值仅限于深层癌症和淋巴结负担较重的患者。未来关于辅助治疗作用的研究应区别对待这两种癌症，指南应反映辅助治疗在组织病理学上适当的生存价值。
