• Bo Jan Noordman, David van Klaveren, Mark I van Berge Henegouwen, Wijnhoven Bas P L BPL Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands., Suzanne S Gisbertz, Sjoerd M Lagarde, Ate van der Gaast, Hulshof Maarten C C M MCCM Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands., Katharina Biermann, Ewout W Steyerberg, van Lanschot J Jan B JJB Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands., and also on behalf of the CROSS-study group.
• Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
• Ann. Surg. 2018 May 1; 267 (5): 892-897.

ObjectiveTo compare overall survival in patients with esophageal adenocarcinoma who underwent transhiatal esophagectomy (THE) with limited lymphadenectomy or transthoracic esophagectomy (TTE) with extended lymphadenectomy with or without neoadjuvant chemoradiotherapy (nCRT).BackgroundThe application of neoadjuvant therapy might change the association between the extent of lymphadenectomy and survival in patients with esophageal adenocarcinoma. This may influence the choice of surgical approach in patients treated with nCRT.MethodsPatients with potentially curable subcarinal esophageal adenocarcinoma treated with surgery alone or nCRT followed by surgery in 7 centers were included. The effect of surgical approach on overall survival, differentiated by the addition or omission of nCRT, was analyzed using a multivariable Cox regression model that included well-known prognostic factors and factors that might have influenced the choice of surgical approach.ResultsIn total, 701 patients were included, of whom 318 had TTE with extended lymphadenectomy and 383 had THE with limited lymphadenectomy. TTE had differential effects on survival (P for interaction = 0.02), with a more favorable prognostic effect in patients who were treated with surgery alone [hazard ratio (HR) = 0.77, 95% confidence interval (CI) 0.58-1.03]. This association was statistically significant in a subgroup of patients with 1 to 8 positive lymph nodes in the resection specimen (HR = 0.62, 95% CI 0.43-0.90). The favorable prognostic effect of TTE over THE was absent in the nCRT and surgery group (HR = 1.16, 95% CI 0.80-1.66) and in the subgroup of nCRT patients with 1 to 8 positive lymph nodes in the resection specimen (HR = 1.00, 95% CI 0.61-1.68).ConclusionsCompared to surgery alone, the addition of nCRT may reduce the need for TTE with extended lymphadenectomy to improve long-term survival in patients with esophageal adenocarcinoma.

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