Patterns of Recurrence and Long-Term Survival of Minimally Invasive Esophagectomy Versus Open Esophagectomy for Locally Advanced Esophageal Cancer Treated with Neoadjuvant Chemotherapy: a Propensity Score–Matched Analysis

Abstract

BackgroundThe use of minimally invasive esophagectomy (MIE) as a treatment for patients with esophageal cancer has recently become more common worldwide. However, differences in the pattern of recurrence between MIE and open esophagectomy (OE) using the transthoracic approach have not been fully investigated, particularly in patients treated with neoadjuvant chemotherapy. MethodsWe searched the prospective databases of two institutes for patients with esophageal cancer who underwent neoadjuvant chemotherapy followed by esophagectomy between 2011 and 2018. Propensity score–matched analysis was performed to reduce bias from confounding patient-related variables. Operative outcomes, regionally harvested lymph nodes (LNs), recurrence pattern, and prognosis were investigated in two groups. ResultsWe identified 410 patients who underwent OE (n = 263) and MIE (n = 147). After propensity score matching, 131 pairs of patients were selected. There were no significant differences in baseline characteristics after matching. The total number of harvested LNs in both groups was similar (55.1 vs. 58.9, P = 0.132). The incidence of LN recurrence in the MIE group was significantly lower than that in the OE group (27% vs. 15%, P = 0.010). In particular, the incidence of mediastinal LN recurrence in the MIE group was significantly lower than that in the OE group (16% vs. 6%, P = 0.017). There were no significant differences between the two groups in hematogenous (19% vs.12%, P = 0.173), dissemination (5% vs. 4%, P = 0.769), local (4% vs. 1%. P = 0.213), and other recurrence (3% vs. 3%, P = 1.000). The 3-year disease-free and overall survival of MIE were significantly better than OE (71.4% vs. 50.5%, P = 0.004 and 80.3% vs. 61.2%, P = 0.002, respectively). Multivariate analysis showed that the thoracic approach (OE vs. MIE) (HR 1.93, P = 0.004) was an independent prognostic factor, along with the pathological N stage (HR 3.05, P < 0.001). ConclusionsMIE has less intramediastinal LN recurrence than OE and may lead to a better long-term prognosis in patients with advanced esophageal cancer who underwent neoadjuvant chemotherapy.