The impact of operative approach for oesophageal cancer on outcome: The transhiatal approach may influence circumferential margin involvement
ABSTRACT Surgery for oesophageal cancer remains the only means of cure for invasive tumours. It is claimed that the surgical approach for these cancers impacts on morbidity and may influence the ability to achieve tumour clearance and therefore survival, however there is no conclusive evidence to support one approach over another. This study aims to determine the impact of operative approach on tumour margin involvement and survival.
Data were extracted from the Scottish Audit of Gastric and Oesophageal Cancer (SAGOC), a prospective population-based audit of all oesophageal and gastric cancers in Scotland between 1997 and 1999 with a minimum of five-year follow up. Analysis focused on the three commonest approaches (Ivor Lewis n = 140, transhiatal n = 68, left thoraco-laparotomy n = 142) for oesophageal cancer.
Operative approach had no significant impact on post-operative morbidity, mortality, overall margin involvement and survival. Transhiatal approach resulted in significantly more circumferential margin involvement (p = 0.019), and the presence of circumferential margin involvement significantly reduced five-year survival (median survival 13 months) compared to no margin involvement (median survival 25 months, p = 0.001).
Surgical approach for oesophageal cancer had no significant effect on morbidity, post-operative mortality and five-year survival. Non-selective use of the transhiatal approach is associated with a significantly greater circumferential margin involvement, with positive circumferential margin impacting adversely on 5-year survival.
SourceAvailable from: Cheng Zhan[Show abstract] [Hide abstract]
ABSTRACT: The Ivor Lewis and Sweet approaches are the two most widely used open transthoracic esophagectomy techniques. We evaluated and compared the therapeutic efficacy of these two approaches to determine the appropriate method to treat middle or lower third esophageal carcinomas. We retrospectively reviewed patients who underwent esophagectomy with the Sweet (n = 748) and Ivor Lewis (n = 167) approaches at Zhongshan Hospital, Fudan University between January 2007 and December 2010. Patients with preoperatively identified superior mediastinal lymph node metastases, high-level lesions (above the carina), and benign tumors were excluded. Perioperative-related indicators and 5-year survival rates were compared between groups. Compared with the Ivor Lewis approach, the Sweet approach has a shorter operative time (181 ± 71 minutes versus 208 ± 63 minutes; p < 0.001), less blood loss (167 ± 71 mL versus 179 ± 87 mL; p = 0.043), and a lower incidence of transfusion (8.7% versus 13.8%; p = 0.044) and postoperative complications (12.3% versus 20.4%; p = 0.002). The Ivor Lewis approach was more likely to result in wound infection (3.2% versus 7.8%; p = 0.010) and delayed gastric emptying (1.7% versus 4.7%; p = 0.046). There was no significant difference between groups with regard to the number of lymph nodes harvested or total number of patients with lymph node metastases. There was no significant difference in locoregional recurrence, distant recurrence, or 5-year survival between approaches. The Sweet approach has many advantages for the treatment of middle or lower third esophageal carcinomas. It is a safe, effective, and worthwhile approach in modern thoracic surgery.The Annals of thoracic surgery 03/2014; 97(5). DOI:10.1016/j.athoracsur.2014.01.034 · 3.65 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: Multiple factors are implicated in the long-term survival of patients who have undergone esophagectomy, among these the involvement of longitudinal and circumferential resection margins are well known important prognostic factors. A few studies have assessed the impact of the operative approach on the status of the resection margins, and the data are not well reported, often unclear and, more importantly, there is no scientific evidence or published guideline on what the optimal proximal, distal or circumferential resection margin clearance should be. Owing to the lack of clarity on these points, we undertook a systematic literature review of the impact of longitudinal and circumferential resection margins in patients with operable esophageal cancer, the prognostic significance of margin involvement and the role of neoadjuvant therapy.Future Oncology 04/2014; 10(5):891-901. DOI:10.2217/fon.13.241 · 2.61 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: The prognostic significance of an incomplete esophageal cancer resection due to a positive microscopic radial margin remains unclear. The aim of this study is to examine the relationship between radial margin status and oncologic outcomes. We performed a retrospective review of esophageal cancer resections between 2004 and 2012. Radial margin status was defined according to the College of American Pathologists. Exclusion criteria were complete pathologic response (n = 12), positive proximal or distal margin (n = 11), R2 resection (n = 5), and carcinoma in situ (n = 2). Of 154 patients, 30 (19%) had a positive radial margin (RM+) and 124 (81%) had a complete resection (R0). The 2 groups were similar with respect to age, gender, proportion of squamous tumors, middle thoracic tumor location, rate of neoadjuvant chemoradiation and adjuvant radiation, transhiatal approach, number of examined lymph nodes, and length of proximal and distal margins. In patients with stage III, the locoregional recurrence-free interval was similar between groups; however, RM+ was associated with a 17-month decrease in the median time to distant recurrence (RM+ = 7 months [95% confidence interval, 4-14]; R0 = 24 months [median not reached]; P < .01). The median survival was also significantly decreased by 12 months in the RM+ group (RM+ = 13 months [95% confidence interval, 7-26]; R0 = 25 months [95% confidence interval, 20-30]; P = .04). An isolated, positive microscopic radial margin was associated with a greater risk for distant recurrence. There was no impact on locoregional disease control. The role of adjuvant, systemic therapy in patients with an isolated, microscopically RM+ merits further evaluation. Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.Journal of Thoracic and Cardiovascular Surgery 10/2014; DOI:10.1016/j.jtcvs.2014.10.040 · 3.99 Impact Factor