ABSTRACT
BACKGROUND: Neoadjuvant chemoradiotherapy (nCRT) and surgery have been recommended as the standard treatments for locally advanced esophageal squamous cell carcinoma (ESCC). In addition, nodal metastases decreased in frequency and changed in distribution after neoadjuvant therapy. This study aimed to examine the optimal strategy for lymph node dissection (LND) in patients with ESCC who underwent nCRT. METHODS: The hazard ratios (HRs) for overall survival (OS) and disease-free survival (DFS) were calculated using the Cox proportional hazard model. To determine the minimal number of LNDs (n-LNS) or least station of LNDs (e-LNS), the Chow test was used. RESULTS: In total, 333 patients were included. The estimated cut-off values for e-LNS and n-LNS were 9 and 15, respectively. A higher number of e-LNS was significantly associated with improved OS (HR: 0.90; 95% CI 0.84-0.97, P = 0.0075) and DFS (HR: 0.012; 95% CI: 0.84-0.98, P = 0.0074). The e-LNS was a significant prognostic factor in multivariate analyses. The local recurrence rate of 23.1% in high e-LNS is much lower than the results of low e-LNS (13.3%). Comparable morbidity was found in both the e-LNS and n-LND subgroups. CONCLUSION: This cohort study revealed an association between the extent of LND and overall survival, suggesting the therapeutic value of extended lymphadenectomy during esophagectomy. Therefore, more lymph node stations being sampled leads to higher survival rates among patients who receive nCRT, and standard lymphadenectomy of at least 9 stations is strongly recommended.
Subject(s)
Carcinoma, Squamous Cell , Esophageal Neoplasms , Esophageal Squamous Cell Carcinoma , Humans , Esophageal Squamous Cell Carcinoma/surgery , Esophageal Squamous Cell Carcinoma/pathology , Esophageal Neoplasms/surgery , Carcinoma, Squamous Cell/surgery , Cohort Studies , Prognosis , Lymph Node Excision , Lymph Nodes/surgery , Lymph Nodes/pathology , Neoadjuvant Therapy , Esophagectomy , Neoplasm Staging , Retrospective StudiesABSTRACT
BACKGROUND: Transthoracic hybrid minimally invasive esophagectomy (HMIE) is frequently performed in patients with esophageal cancer. However, no conclusive benefit has been defined for HMIE compared with open esophagectomy (OE) or totally MIE (TMIE). The aim of this meta-analysis is to evaluate the effectiveness of HMIE compared with OE and TMIE. METHODS: PubMed, Embase (via OVID) and Cochrane databases were comprehensively searched for relevant studies up to January 2019. Studies comparing the efficacy of transthoracic HMIE with OE or TMIE were included in this meta-analysis. RESULTS: Twenty-nine relevant studies comprising 3994 patients were identified and included in the analysis of HMIE vs OE. HMIE decreased the incidence of postoperative total morbidity (OR = 0.66, 95% CI 0.55 to 0.80, p = 0.00), pneumonia (OR = 0.55, 95% CI 0.45 to 0.66, p = 0.00), in-hospital mortality (OR = 0.54, 95% CI 0.36 to 0.83, p = 0.01), duration of hospitalization (SMD=-1.03, 95% CI -1.73 to -0.33, p = 0.00) and the estimated intraoperative blood loss (SMD=-1.01, 95% CI -1.62 to -0.40, p = 0.00) compared with OE. Twenty-one relevant studies comprising 3007 patients were identified and included in the analysis of HMIE vs TMIE. HMIE increased estimated intraoperative blood loss [standardized mean difference (SMD) = 1.02, 95% CI 0.45 to 1.58, p = 0.00] and the incidence of postoperative pneumonia (OR = 1.69, 95% CI 1.26 to 2.26, p = 0.00) compared with TMIE. No statistical differences were observed for other surgical outcomes. CONCLUSIONS: In our opinion, HMIE is a promising surgical technique. But further RCTs are still needed to confirm the advantages and disadvantages of HMIE mentioned above.
