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The Role Of Endoscopic Resection In Early-stage Esophageal Adenocarcinoma: Esophagectomy Is Associated With Improved Survival In Patients Presenting With Clinical Stage T1bN0M0 Disease
*James A Swanson1, *Michael Littau1, *Celsa Tonelli2, *Tyler Cohn2, Fredrick A Luchette3, *Zaid Abdelsattar4, Marshall S Baker3
1Stritch School of Medicine, Loyola University Chicago, Maywood, IL;2Department of Surgery, Loyola University Medical Center, Maywood, IL;3Department of Surgery, Edward Hines Jr Veterans Administration Hospital, Hines, IL; Department of Surgery, Loyola University Medical Center, Maywood, IL;4Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL

OBJECTIVE(S): Studies evaluating endoscopic resection (ER) in early clinical stage (cT1N0M0) esophageal adenocarcinoma (EAC) include small numbers of patients with cT1b tumors. The role of ER in EAC remains incompletely defined.
METHODS: We queried the National Cancer Database to identify patients presenting with EAC between 2010 and 2017. Those treated with neoadjuvant chemoradiotherapy and ablation were excluded. Patients undergoing ER for cT1a and cT1b tumors were 1:1 propensity matched for demographics, comorbid disease, tumor grade and size to those undergoing esophagectomy for like cT stage. 5-year overall survival (OS) for matched-cohorts was compared by Kaplan Meier method.
RESULTS: 3157 patients met inclusion criteria. 2024 (64.1%) had cT1a; 1133 (35.9%) cT1b disease. Among those with cT1a tumors, 461 (22.8%) underwent esophagectomy, 1357 (67.0%) ER, and 206 (10.2%) treatment with chemoradiotherapy alone. Among those with cT1b tumors, 649 (57.3%) underwent esophagectomy, 293 (25.9%) ER and 191 (16.8%) chemoradiotherapy. On unadjusted comparison, patients undergoing ER for EAC demonstrated rates of OS similar to those for patients undergoing esophagectomy but better than those for patients treated with chemoradiotherapy (73.1% vs. 75.5% vs. 26.1%, p<0.001). By multivariable regression, patients with advanced (69-75 years) age (OR 3.08; 95% CI [2.27, 4.19]) were more likely to undergo ER while those with cT1b tumors (OR 0.16; 95% CI [0.14, 0.20]), > 3cm in size (OR 0.45; 95% CI [0.35, 0.59]) and poorly differentiated histology (OR 0.54; 95% CI [0.41, 0.70]) were less likely to undergo ER than esophagectomy. On comparison of matched cohorts, patients undergoing ER for cT1b tumors demonstrated lower rates of OS than those undergoing esophagectomy (58.8% vs. 73.7%, p<0.0001) while patients undergoing ER for cT1a tumors demonstrated rates of OS similar to those for patients undergoing esophagectomy (79.1% vs. 80.2%, p=0.67).
CONCLUSIONS: Esophagectomy is associated with improved OS relative to ER in patients presenting with cT1bN0M0 but not in those with cT1a EAC. ER should be reserved for patients with cT1a EAC and those with cT1b EAC unfit for esophagectomy.


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