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Patterns of Recurrence after Transhiatal Esophagectomy for Esophageal Cancer: The Role of Mediastinal Lymphadenectomy in the Age of Neoadjuvant Therapy
*Daniel G Solomon, *Chantae Sullivan, Ronald R Salem
Yale University School of Medicine, New Haven, CT

Objective: Since the widespread adoption of neoadjuvant chemoradiotherapy for esophageal cancer, there has paucity of data regarding recurrence patterns following transhiatal esophagectomy. Specifically, little is known about the role of mediastinal lymphadectomy, which is not performed during transhiatal resection, in preventing mediastinal nodal recurrences.
Design: Retrospective cohort trial.
Setting: Single surgeon, academic referral center, inpatient service.
Patients: Seventy-one consecutive patients with squamous or adenocarcinoma of the gastroesophageal junction or distal esophagus who underwent neoadjuvant chemoradiotherapy followed by transhiatal esophagectomy were analyzed.
Interventions: N/A.
Main Outcome Measured: Incidence and location of tumor recurrences and pre- and post operative clinical and treatment parameters were recorded.
Results: Between February 1998 and June 2009, 74 consecutive patients underwent neoaduvant chemoradiotherapy followed by transhiatal esophagectomy. There were 3 perioperative mortalities (4.%). Median follow-up was 28.5 months (0-154 months). There were 40 recurrences (54%) thirty (75%) were metastatic to distant organs (lung 43.3%, liver 26.7%, bone 13.3%, brain 10%, abdominal wall 6.7%), 5 had peritoneal recurrences(16.7%) and four (13.3%) had anastomotic recurrences. Only 1 patient (3.3%) experienced a recurrence in the mediastinal nodal basin. The number of nodes sampled was similar between patients with and without recurrence (9.6 ± 1.1 vs. 11.6 ± 1.0 nodes, p=0.17). However, a greater proportion of patients with recurrences were node positive at the time of resection (42.5% vs 16.15, p=0.02). Five year disease free survival and overall survival were 61.6% and 60.3% respectively.
Conclusion: Mediastinal nodal recurrence accounts for an exceedingly small proportion of treatment failures. Regardless of the extent of nodal dissection, pN0 status is an important predictor of recurrence free survival. More aggressive mediastinal lymphadenectomy may not improve local control of esophageal cancer.


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Abstract Submission Deadline:
May 5, 2014

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August 13, 2014

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August 11, 2014
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