Influence of Neoadjuvant Radiation Dose on Patients Undergoing Esophagectomy and Survival in Locally Advanced Esophageal Cancer

• Published in: Journal of gastrointestinal surgery 2019-04, Vol.23 (4), p.670-678
• Main Authors: Ising, Mickey S., Marino, Katy, Trivedi, Jaimin R., Rojan, Adam A., Dunlap, Neal E., van Berkel, Victor, Fox, Matthew P.
• Format: Article
• Language: English
• Subjects: 2018 SSAT Plenary Presentation; Adenocarcinoma - mortality; Adenocarcinoma - pathology; Adenocarcinoma - radiotherapy; Adenocarcinoma - surgery; Adult; Aged; Aged, 80 and over; Carcinoma, Squamous Cell - mortality; Carcinoma, Squamous Cell - pathology; Carcinoma, Squamous Cell - radiotherapy; Carcinoma, Squamous Cell - surgery; Databases, Factual; Esophageal cancer; Esophageal Neoplasms - mortality; Esophageal Neoplasms - pathology; Esophageal Neoplasms - radiotherapy; Esophageal Neoplasms - surgery; Esophagectomy; Esophagus; Female; Follow-Up Studies; Gastroenterology; Gastrointestinal surgery; Health risk assessment; Humans; Male; Medicine; Medicine & Public Health; Middle Aged; Neoadjuvant Therapy; Neoplasm Staging; Propensity Score; Radiation Dosage; Radiotherapy, Adjuvant; Surgery; Treatment Outcome
• ISSN: 1091-255X; 1873-4626
• DOI: 10.1007/s11605-019-04141-z

Background Neoadjuvant chemoradiotherapy followed by resection is standard of care for patients with locally advanced esophageal cancer, however, a significant portion of these patients do not undergo surgical intervention. This study evaluates radiation dose and other factors associated with undergoing esophageal resection and their impact on outcomes including survival. Methods Patients diagnosed with esophageal cancer between 2010 and 15 were queried from the National Cancer Database and stratified into low-dose radiation (41.4 Gy) (LDR) or high-dose radiation (50.0 or 50.4 Gy) (HDR) groups. Multivariable Logistic and Cox Regression analyses were performed to investigate the effect of multiple variables on the likelihood of undergoing esophagectomy and overall survival, respectively. Propensity score matching was performed to reduce bias between groups. Results A total of 3633 patients met study criteria with 3005 (82.7%) undergoing esophagectomy. A greater proportion received HDR (3163 (87.1%)) than LDR (470 (12.9%)). The use of LDR increased from 4.7% ( n  = 22) in 2010 to 20.7% ( n  = 154) in 2015. Factors associated with undergoing esophagectomy included LDR, adenocarcinoma histology, and younger age. Radiation dosage did not impact overall survival, but undergoing esophagectomy was associated with improved survival. After propensity matching, a greater portion of the LDR group underwent esophagectomy (87.0 vs 81.1%, p  = 0.013). There was no difference in R0 3 resection (93.2 vs 92.4%, p  = 0.678) or complete pathologic response (19.3 vs 21.5%, p  = 0.442) between LDR and HDR groups. Conclusion The use of LDR is increasing but still underutilized. LDR is associated with increased rates of esophagectomy without negatively impacting overall survival, R0 resection, or complete pathologic response.