Original article
General thoracic
Adjuvant Therapy for Positive Nodes After Induction Therapy and Resection of Esophageal Cancer

Presented at the Fifty-first Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 24–28, 2015.
https://doi.org/10.1016/j.athoracsur.2015.09.001Get rights and content

Background

The value of adjuvant chemotherapy for patients with positive lymph nodes (+LNs) after induction therapy and resection of esophageal cancer is controversial. This study assesses survival benefit of adjuvant chemotherapy in this cohort.

Methods

We analyzed our single-institution database for patients with +LNs after induction therapy and resection of primary esophageal cancer between 2000 and 2013. Factors associated with survival were analyzed using a Cox proportional hazards model.

Results

A total of 101 of 764 esophagectomy patients received induction and had +LNs on final pathologic examination. Forty-five also received adjuvant therapy: 37 of 45 (82%) received chemotherapy alone, 1 of 45 (2%) received radiation alone, and 7 of 45 (16%) received both. Pathologic stage was IIB in 21 (47%), IIIA in 19 (42%), and IIIB in 5 (11%). In 56 node-positive patients with induction but not adjuvant therapy, pathologic stage was IIB in 28 (50%), IIIA in 18 (32%), IIIB in 7 (13%), and IIIC in 3 (5%). Neither age nor comorbidity score differed between cohorts. Adjuvant patients experienced a shorter hospital length of stay (mean, 10 days [range, 6 to 33 days] versus 11 days [range, 7 to 67 days]; p = 0.03]. Median survival favored the adjuvant group: 24.0 months (95% confidence interval, 16.6 to 32.2 months) versus 18.0 months (95% confidence interval, 11.1 to 25.0 months); p = 0.033). Multivariate Cox regression identified adjuvant therapy, length of stay, and number of +LNs as influential for survival.

Conclusions

Optimal management of node-positive patients after induction therapy and esophagectomy remains unclear, but in this series, adjuvant therapy, length of stay, and number of +LNs impacted survival. A prospective trial may reduce potential bias and guide the evaluation of adjuvant therapy in this patient population.

Section snippets

Patients and Methods

All patients undergoing resection for primary esophageal cancer between January 2000 and July 2013 at Barnes-Jewish Hospital, St. Louis, MO, were identified from our expanded version of The Society of Thoracic Surgeons database and retrospectively analyzed in accordance with a protocol approved by the institutional review board at the Washington University School of Medicine (Fig 1). Inclusion criteria included esophagectomy for esophageal cancer, positive lymph nodes on pathologic examination,

Results

A total of 764 patients received an esophagectomy for primary esophageal cancer during the study period. Of these, 101 patients (13%) met inclusion criteria with one or more +LNs on pathologic examination after induction therapy and esophagectomy. The specific induction chemotherapeutic agent or strategy for 10 patients was not clear. Of the remaining 91, 97% of patients underwent a multidrug regimen, with cisplatin and 5-fluorouracil as the most common drug combination (n = 43 of 91 patients;

Comment

Although most accept the value of induction chemoradiotherapy before esophagectomy, and naïve patients are more commonly fit enough to tolerate adjuvant chemoradiotherapy, the utility of adjuvant therapy for patients with +LNs and who have already experienced the burdens of both induction therapy and esophagectomy remains poorly defined.

Previously reported data have shown that adjuvant therapy may improve survival in some select populations 11, 12, 13, although none of these studies included

References (19)

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