Extended Transthoracic Resection Compared With Limited... : Annals of Surgery (original) (raw)

Original Articles

Extended Transthoracic Resection Compared With Limited Transhiatal Resection for Adenocarcinoma of the Mid/Distal Esophagus

Five-Year Survival of a Randomized Clinical Trial

Omloo, Jikke M. T. MD*; Lagarde, Sjoerd M. MD*; Hulscher, Jan B. F. MD*; Reitsma, Johannes B. MD, PhD†; Fockens, Paul MD, PhD‡; van Dekken, Herman MD, PhD§; ten Kate, Fiebo J. W. MD¶; Obertop, Huug MD∥; Tilanus, Hugo W. MD, PhD∥; van Lanschot, J Jan B. MD∥

From the *Departments of Surgery, †Clinical Epidemiology, Biostatistics, and Bioinformatics, and ‡Gastroenterology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; §Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands; ¶Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; and ∥Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands.

Supported by ZonMw Health Care Efficiency Research (945-04-510; to J. M. T. O.).

Supported by the Maag Lever Darm Stichting (Dutch Digestive Foundation, 04-77; to S. M. L.).

Supported by the Dutch Health Care Insurance Funds Council (1996-041; to J. B. F. H.).

Reprints: Jikke M. T. Omloo, Department of Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. E-mail: [email protected].

Objective:

To determine whether extended transthoracic esophagectomy for adenocarcinoma of the mid/distal esophagus improves long-term survival.

Background:

A randomized trial was performed to compare surgical techniques. Complete 5-year survival data are now available.

Methods:

A total of 220 patients with adenocarcinoma of the distal esophagus (type I) or gastric cardia involving the distal esophagus (type II) were randomly assigned to limited transhiatal esophagectomy or to extended transthoracic esophagectomy with en bloc lymphadenectomy. Patients with peroperatively irresectable/incurable cancer were excluded from this analysis (n = 15). A total of 95 patients underwent transhiatal esophagectomy and 110 patients underwent transthoracic esophagectomy.

Results:

After transhiatal and transthoracic resection, 5-year survival was 34% and 36%, respectively (P = 0.71, per protocol analysis). In a subgroup analysis, based on the location of the primary tumor according to the resection specimen, no overall survival benefit for either surgical approach was seen in 115 patients with a type II tumor (P = 0.81). In 90 patients with a type I tumor, a survival benefit of 14% was seen with the transthoracic approach (51% vs. 37%, P = 0.33). There was evidence that the treatment effect differed depending on the number of positive lymph nodes in the resection specimen (test for interaction P = 0.06). In patients (n = 55) without positive nodes locoregional disease-free survival after transhiatal esophagectomy was comparable to that after transthoracic esophagectomy (86% and 89%, respectively). The same was true for patients (n = 46) with more than 8 positive nodes (0% in both groups). Patients (n = 104) with 1 to 8 positive lymph nodes in the resection specimen showed a 5-year locoregional disease-free survival advantage if operated via the transthoracic route (23% vs. 64%, P = 0.02).

Conclusion:

There is no significant overall survival benefit for either approach. However, compared with limited transhiatal resection extended transthoracic esophagectomy for type I esophageal adenocarcinoma shows an ongoing trend towards better 5-year survival. Moreover, patients with a limited number of positive lymph nodes in the resection specimen seem to benefit from an extended transthoracic esophagectomy.