Locally Advanced Adenocarcinoma of the Esophagus: Is Esophagectomy Associated with Improved Overall Survival?

BACKGROUND: Esophagectomy in locally advanced esophageal adenocarcinoma is challenging and carries risk. The value of esophagectomy in locally advanced esophageal adenocarcinoma is not well-defined.

STUDY DESIGN: The National Cancer Database was used to identify patients with cT4 esophageal adenocarcinoma from 2004-2020. Multivariable regression was used to identify factors associated with use of esophagectomy. Cox modeling was used to identify factors associated with all-cause mortality. Patients undergoing esophagectomy were 1:1 propensity score-matched to patients treated non-surgically. Kaplan-Meier analysis was used to compare five-year overall survival (OS).

RESULTS: 3,703 patients met inclusion criteria. 541 (15%) underwent esophagectomy, 3,162 (85%) did not. Age ≤ 65 (aOR 1.69, [1.33, 2.14]), white race (aOR 2.98, [2.24, 3.96]), treatment in academic centers (aOR 1.64, [1.33, 2.02]), private insurance (aOR 1.88, [1.50, 2.36]), and tumors <6cm (aOR 1.86, [1.44, 2.40]) were associated with use of esophagectomy. Government/lack of insurance (HR 1.23, [1.12, 1.35]), income <$46,000 (HR 1.11, [1.03, 1.20]), treatment in non-academic centers (HR 1.16, [1.07, 1.25]), CCI ≥ 1 (HR 1.22, [1.12, 1.32]), and tumors ≥ 6 cm (HR 1.20, [1.09, 1.32]) were associated with risk of all-cause mortality. Esophagectomy (HR 0.50, [0.44, 0.56]) and systemic therapy (HR 0.40, [0.37, 0.43]) were associated with decreased risk of all-cause mortality. Patients undergoing esophagectomy had higher rates of 5-year OS (27.4% vs 13.2%, p<0.0001) and longer median OS (24.71 vs. 10.09 months, p<0.0001). Among cT4b patients, those who underwent esophagectomy had higher rates of 5-year OS (24.5% vs 12.3%, p<0.0001) and longer median OS (25.53 vs. 11.01 months, p<0.0001).

CONCLUSIONS: In cT4 esophageal adenocarcinoma, esophagectomy is associated with improved rates of 5-year OS compared to non-surgical treatment.