• Naita M Wirsik, Cezanne D Kooij, Niall Dempster, Nerma Crnovrsanin, Noel E Donlon, Eren Uzun, Kunal Bhanot, Henrik Nienhüser, Daniela Polette, Kammy Kewani, Peter Grimminger, Daniel Reim, Florian Seyfried, Hans F Fuchs, Suzanne S Gisbertz, Christoph-Thomas Germer, Jelle P Ruurda, Fredrik Klevebro, Wolfgang Schröder, Magnus Nilsson, John V Reynolds, Mark I Van Berge Henegouwen, Sheraz Markar, Richard Van Hillegersberg, Thomas Schmidt, and Christiane J Bruns.
• Department of General, Visceral, Cancer and Transplant Surgery, University Hospital of Cologne, Cologne, Germany.
• Ann. Surg. 2024 Nov 1; 280 (5): 799807799-807.

ObjectiveTo evaluate outcomes after primary surgery (PS) or neoadjuvant treatment followed by surgery (NAT/S) in cT2 staged adenocarcinomas of the esophagus (EAC) and gastroesophageal junction (GEJ), a multinational high-volume center study was undertaken.BackgroundThe optimal treatment approach with either NAT/S or PS for clinically staged cT2cN any or cT2N0 EAC and GEJ remains unknown due to the lack of randomized controlled trials.MethodsA retrospective analysis of prospectively maintained databases from 10 centers was performed. Between January 2012 and August 2023, 645 patients who fulfilled inclusion criteria of GEJ Siewert type I, II, or EAC with cT2 status at diagnosis underwent PS or NAT/S with curative intent. The primary endpoint was overall survival (OS).ResultsIn the cT2cN any cohort, 192 patients (29.8%) underwent PS and 453 (70.2%) underwent NAT/S. In all cT2cN0 patients (n = 333), NAT/s remained the more frequent treatment (56.2%). Patients undergoing PS were in both cT2 cohorts older ( P < 0.001) and had a higher American Society of Anesthesiologists classification ( P < 0.05). R0 resection showed no differences between NAT/S and PS in both cT2 cohorts ( P > 0.4).Median OS was 51.0 months in the PS group (95% CI: 31.6-70.4) versus 114.0 months (95% CI: 53.9-174.1) in the NAT/S group ( P = 0.003) of cT2cN any patients. For cT2cN0 patients, NAT/S was associated with longer OS ( P = 0.002) and disease-free survival ( P = 0.001). After propensity score matching of the cT2N0 patients, survival benefit for NAT/S remained ( P = 0.004). Histopathology showed that 38.1% of cT2cN any and 34.2% of cT2cN0 patients were understaged.ConclusionsDue to the unreliable identification of cT2N0 disease, all patients should be offered a multimodal therapeutic approach.Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.

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