Long-term survival from adenocarcinoma of the esophagus after transthoracic and transhiatal esophagectomy

Kjell K Ovrebo,Asgaut Viste,Knut Svanes,Ole D Laerum,Stein A Lie

doi:10.1186/1477-7819-10-130

Abstract

BackgroundThe effects of transthoracic or transhiatal esophagectomy on the long-term survival of patients who had adenocarcinoma of the esophagus were compared, as were factors applicable in preoperative stratification of patient treatment.MethodsA cohort of 147 consecutive patients with adenocarcinoma of the esophagus was evaluated for esophagectomy between 1984 and 2000. The patients were followed prospectively and observed survival rates of patients with a transthoracic or transhiatal approach to esophagectomy were compared by standardized mortality ratio (SMR) and relative mortality ratio (RMR) using the expected survival of a matched Norwegian population.ResultsA R0 resection was performed by transthoracic (n = 33) or a transhiatal (n = 55) esophagectomy in 88 (60%) patients with a median age of 61 (range: 35–77) and 70 (42–88) years, respectively (P <0.001). Tumor stages and other possible risk factors were similar in the two groups. Transthoracic or transhiatal esophagectomy resulted in a median survival time of 20.5 (95% confidence interval (CI): 10.4–57.6) and 16.4 (10.6–28.7) months, respectively. The respective survival rates were 31.2% and 27.8% by 5 years, and 21.3% and 16.6% by 10 years with an overall RMR of 1.14 (P = 0.63). Median survival time in the absence or presence of lymph node metastases was 74.0 (95% CI: 17.5–166.4) and 10.7 (7.9–14.9) months. The corresponding survival rates by 10 years with non-involved or involved nodes were 48.9% and 3.8% respectively (RMR 2.22, P = 0.007). Patients with a pT1-tumor were few and the survival rate was not very different from that of the general population (SMR = 1.7, 95% CI: 0.7–4.1). The median survival time of patients with a pT2-tumor was 30.4 (95% CI: 9.0–142) months and with a pT3-tumor 14 (9.2–16.4) months. The survival rates by 10 years among patients with a pT1 tumor were 57.0% (95% CI: 14.9–78.9), pT2 33.3% (11.8–52.2), and pT3 7.1% (1.9–15.5). The relative mortality for T3 stages compared to T1 stages was statistically significant (RMR = 3.22, P = 0.024).ConclusionTransthoracic and transhiatal esophagectomy are both effective approaches for treatment of adenocarcinoma of the esophagus and survival of more than 10 years can be expected without adjuvant chemotherapy. However, increasing depth of tumor invasion and lymph node metastases reduce life expectancy.

Highlights

The effects of transthoracic or transhiatal esophagectomy on the long-term survival of patients who had adenocarcinoma of the esophagus were compared, as were factors applicable in preoperative stratification of patient treatment
Transthoracic esophagectomy is reported with superior survival rates compared with transhiatal esophagectomy [4,5,6,7], but the opposite has been reported [8]
Other reports indicate that gastrectomy with partial esophagectomy and transhiatal esophagectomy for cardiac cancers obtain similar survival rates [11,12,13,14]

Summary

Introduction

The effects of transthoracic or transhiatal esophagectomy on the long-term survival of patients who had adenocarcinoma of the esophagus were compared, as were factors applicable in preoperative stratification of patient treatment. Surgery dominates the treatment of local disease, comparative studies between different surgical approaches are few and controversies still exists on the extent of esophagus resection, lymph node dissection and preferred fields of dissection [3]. A Dutch trial could not identify any statistical significant difference between the survival rates of patients subject to transthoracic esophagectomy with extended en bloc lymph node resection or transhiatal esophagectomy with limited abdominal lymph node dissection [9,10]. Minimal invasive approaches to esophagectomy have increased exponentially in England, but mortality rates and length of stay is similar to that of patients treated with conventional surgery [15]

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Conclusion