title: Esophagectomy Timing After Neoadjuvant Therapy for Distal Esophageal Adenocarcinoma.
abstract: BACKGROUND
  The time elapsed between completion of neoadjuvant therapy and esophagectomy may influence response rate and possibly allow for avoidance of surgical intervention in selected cases ("wait and see" approach). However, a very long postradiation interval has been associated with worsened surgical outcomes in esophageal carcinoma. Therefore we analyzed outcomes of patients with invasive distal esophageal adenocarcinoma treated with neoadjuvant chemoradiation and esophagectomy based on the time elapsed between completion of neoadjuvant chemoradiation and resection.
  
  
  METHODS
  Patients with invasive distal esophageal carcinoma diagnosed between 2003 and 2011 and treated by neoadjuvant chemoradiation followed by esophagectomy within 26 weeks were identified in the National Cancer Data Base (NCDB). Primary outcome measures were 30- and 90-day postsurgical mortality and overall survival.
  
  
  RESULTS
  In all, 4,284 patients aged 60.3 ± 9.4 years were analyzed (mean ± standard deviation). The interval after radiation therapy until esophagectomy was 7.8 ± 3.4 weeks (median, 7.1 weeks). The postradiation interval was 8 weeks or more in 35% of patients. Thirty-day mortality was 2.9% (n = 127), and 90-day mortality was 7.8% (n = 336). A postradiation interval of 9 weeks or more was associated with increased perioperative mortality odds both at the 30-day (adjusted odds ratio [OR], 2.160; 95% confidence interval, 1.099-4.242; p = 0.025) and 90-day follow-up (adjusted OR, 1.912; 95% confidence interval, 1.290-2.835; p < 0.001). Similarly, a postradiation interval of 9 weeks or more was associated with an increased mortality risk (adjusted hazard ratio [HR], 1.194; 95% confidence interval, 1.032-1.380; p = 0.017).
  
  
  CONCLUSIONS
  Perioperative mortality and overall survival are significantly associated with the time interval between neoadjuvant chemoradiation and esophagectomy. A "wait and see" approach after neoadjuvant therapy for esophageal adenocarcinoma may not be safe. Further studies based on more detailed data are needed.
authors.affiliation: Department of Surgery, Mercy Medical Center, Des Moines, Iowa. Electronic address: jan.franko@gmail.com.
authors.forename: Jan
authors.initials: J
authors.lastname: Franko
authors.affiliation: Department of Radiation Oncology, Mercy Medical Center, Des Moines, Iowa.
authors.forename: George
authors.initials: G
authors.lastname: Voynov
authors.affiliation: Department of Surgery, Mercy Medical Center, Des Moines, Iowa.
authors.forename: Charles D
authors.initials: CD
authors.lastname: Goldman
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality* / Q000473:pathology / Q000628:therapy*; D000368:Aged; D059248:Chemoradiotherapy / Q000379:methods; D016208:Databases, Factual; D018572:Disease-Free Survival; D004938:Esophageal Neoplasms / Q000401:mortality* / Q000473:pathology / Q000628:therapy*; D016629:Esophagectomy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000379:methods*; D009361:Neoplasm Invasiveness / Q000473:pathology; D009367:Neoplasm Staging / Q000379:methods; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome; D057832:Watchful Waiting / Q000379:methods