title: Impact of Surgical Approach on Long-term Survival in Esophageal Adenocarcinoma Patients With or Without Neoadjuvant Chemoradiotherapy.
abstract: To compare overall survival in patients with esophageal adenocarcinoma who underwent transhiatal esophagectomy (THE) with limited lymphadenectomy or transthoracic esophagectomy (TTE) with extended lymphadenectomy with or without neoadjuvant chemoradiotherapy (nCRT).
  
  
  
  The application of neoadjuvant therapy might change the association between the extent of lymphadenectomy and survival in patients with esophageal adenocarcinoma. This may influence the choice of surgical approach in patients treated with nCRT.
  
  
  
  Patients with potentially curable subcarinal esophageal adenocarcinoma treated with surgery alone or nCRT followed by surgery in 7 centers were included. The effect of surgical approach on overall survival, differentiated by the addition or omission of nCRT, was analyzed using a multivariable Cox regression model that included well-known prognostic factors and factors that might have influenced the choice of surgical approach.
  
  
  
  In total, 701 patients were included, of whom 318 had TTE with extended lymphadenectomy and 383 had THE with limited lymphadenectomy. TTE had differential effects on survival (P for interaction = 0.02), with a more favorable prognostic effect in patients who were treated with surgery alone [hazard ratio (HR) = 0.77, 95% confidence interval (CI) 0.58-1.03]. This association was statistically significant in a subgroup of patients with 1 to 8 positive lymph nodes in the resection specimen (HR = 0.62, 95% CI 0.43-0.90). The favorable prognostic effect of TTE over THE was absent in the nCRT and surgery group (HR = 1.16, 95% CI 0.80-1.66) and in the subgroup of nCRT patients with 1 to 8 positive lymph nodes in the resection specimen (HR = 1.00, 95% CI 0.61-1.68).
  
  
  
  Compared to surgery alone, the addition of nCRT may reduce the need for TTE with extended lymphadenectomy to improve long-term survival in patients with esophageal adenocarcinoma.
authors.affiliation: Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
authors.forename: Bo Jan
authors.initials: BJ
authors.lastname: Noordman
authors.affiliation: Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
authors.forename: David
authors.initials: D
authors.lastname: van Klaveren
authors.affiliation: Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Mark I
authors.initials: MI
authors.lastname: van Berge Henegouwen
authors.affiliation: Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
authors.forename: Bas P L
authors.initials: BPL
authors.lastname: Wijnhoven
authors.affiliation: Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Suzanne S
authors.initials: SS
authors.lastname: Gisbertz
authors.affiliation: Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.|Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Sjoerd M
authors.initials: SM
authors.lastname: Lagarde
authors.affiliation: Department of Medical Oncology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
authors.forename: Ate
authors.initials: A
authors.lastname: van der Gaast
authors.affiliation: Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Maarten C C M
authors.initials: MCCM
authors.lastname: Hulshof
authors.affiliation: Department of Pathology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
authors.forename: Katharina
authors.initials: K
authors.lastname: Biermann
authors.affiliation: Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
authors.forename: Ewout W
authors.initials: EW
authors.lastname: Steyerberg
authors.affiliation: Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
authors.forename: J Jan B
authors.initials: JJB
authors.lastname: van Lanschot
mesh_terms: D000230:Adenocarcinoma / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D000368:Aged; D059186:Chemoradiotherapy, Adjuvant; D018572:Disease-Free Survival; D004938:Esophageal Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D016629:Esophagectomy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009367:Neoplasm Staging; D009426:Netherlands / Q000453:epidemiology; D049268:Positron-Emission Tomography; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D016896:Treatment Outcome; D014463:Ultrasonography