Neoadjuvant Therapy Vs Upfront Surgery for Clinical T2N0 Esophageal Cancer

A Systematic Review

Biniam Kidane, Robert J. Korst, Benny Weksler, Ashley Farrell, Gail E. Darling, Linda W. Martin, Rishindra Reddy, Inderpal S. Sarkaria

Research output: Contribution to journalReview article

Abstract

Background: The optimal approach to clinical T2N0 (cT2N0) esophageal cancer is unclear. Our objective is to perform a systematic review investigating whether neoadjuvant therapy results in better outcomes compared with upfront surgery in cT2N0 esophageal cancer. Methods: We performed a systematic review and meta-analysis of randomized and nonrandomized studies (1995 to 2017) comparing use of neoadjuvant therapy with upfront surgery in the treatment of cT2N0 esophageal cancer. Independent and duplicate assessment was used. All meta-analytical techniques were performed in RevMan 5.3. Results: Nine cohort studies, including 5433 patients, were included for meta-analysis. Use of neoadjuvant therapy was associated with significantly higher complete resection rates compared with upfront surgery (risk ratio, 0.67; 95% confidence interval, 0.55 to 0.81; P <.001). There was no difference in 5-year overall or recurrence-free survival. There were no significant differences in perioperative mortality as well as perioperative complications, although meta-analysis results are limited by inconsistent reporting of such complications. Lymphovascular invasion and larger tumor size were significant predictors of upstaging. Four of the studies were at high risk of bias. The remaining 5 studies were larger and more robust but were assessed as being of uncertain risk of bias. Conclusions: Use of neoadjuvant therapy was associated with significantly higher complete resection rates compared with upfront surgery although this did not translate to differences in survival outcomes. No differences in perioperative morbidity or mortality were identified. Based on qualitative systematic review, lymphovascular invasion and larger tumor size are potential factors for helping to select those patients who may benefit from neoadjuvant therapy.

Original languageEnglish (US)
Pages (from-to)935-944
Number of pages10
JournalAnnals of Thoracic Surgery
Volume108
Issue number3
DOIs
StatePublished - Sep 1 2019

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Neoadjuvant Therapy
Esophageal Neoplasms
Meta-Analysis
Survival
Mortality
Neoplasms
Cohort Studies
Odds Ratio
Confidence Intervals
Morbidity
Recurrence

All Science Journal Classification (ASJC) codes

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine

Cite this

Neoadjuvant Therapy Vs Upfront Surgery for Clinical T2N0 Esophageal Cancer : A Systematic Review. / Kidane, Biniam; Korst, Robert J.; Weksler, Benny; Farrell, Ashley; Darling, Gail E.; Martin, Linda W.; Reddy, Rishindra; Sarkaria, Inderpal S.

In: Annals of Thoracic Surgery, Vol. 108, No. 3, 01.09.2019, p. 935-944.

Research output: Contribution to journalReview article

Kidane, B, Korst, RJ, Weksler, B, Farrell, A, Darling, GE, Martin, LW, Reddy, R & Sarkaria, IS 2019, 'Neoadjuvant Therapy Vs Upfront Surgery for Clinical T2N0 Esophageal Cancer: A Systematic Review', Annals of Thoracic Surgery, vol. 108, no. 3, pp. 935-944. https://doi.org/10.1016/j.athoracsur.2019.04.008
Kidane, Biniam ; Korst, Robert J. ; Weksler, Benny ; Farrell, Ashley ; Darling, Gail E. ; Martin, Linda W. ; Reddy, Rishindra ; Sarkaria, Inderpal S. / Neoadjuvant Therapy Vs Upfront Surgery for Clinical T2N0 Esophageal Cancer : A Systematic Review. In: Annals of Thoracic Surgery. 2019 ; Vol. 108, No. 3. pp. 935-944.
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AU - Farrell, Ashley

AU - Darling, Gail E.

AU - Martin, Linda W.

AU - Reddy, Rishindra

AU - Sarkaria, Inderpal S.

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AB - Background: The optimal approach to clinical T2N0 (cT2N0) esophageal cancer is unclear. Our objective is to perform a systematic review investigating whether neoadjuvant therapy results in better outcomes compared with upfront surgery in cT2N0 esophageal cancer. Methods: We performed a systematic review and meta-analysis of randomized and nonrandomized studies (1995 to 2017) comparing use of neoadjuvant therapy with upfront surgery in the treatment of cT2N0 esophageal cancer. Independent and duplicate assessment was used. All meta-analytical techniques were performed in RevMan 5.3. Results: Nine cohort studies, including 5433 patients, were included for meta-analysis. Use of neoadjuvant therapy was associated with significantly higher complete resection rates compared with upfront surgery (risk ratio, 0.67; 95% confidence interval, 0.55 to 0.81; P <.001). There was no difference in 5-year overall or recurrence-free survival. There were no significant differences in perioperative mortality as well as perioperative complications, although meta-analysis results are limited by inconsistent reporting of such complications. Lymphovascular invasion and larger tumor size were significant predictors of upstaging. Four of the studies were at high risk of bias. The remaining 5 studies were larger and more robust but were assessed as being of uncertain risk of bias. Conclusions: Use of neoadjuvant therapy was associated with significantly higher complete resection rates compared with upfront surgery although this did not translate to differences in survival outcomes. No differences in perioperative morbidity or mortality were identified. Based on qualitative systematic review, lymphovascular invasion and larger tumor size are potential factors for helping to select those patients who may benefit from neoadjuvant therapy.

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