Date of Award

January 2011

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Ronald Salem

Subject Area(s)

Surgery

Abstract

The pattern of recurrence after neoadjuvant chemoradiotherapy followed by transhiatal esophagectomy with limited mediastinal lymphadenectomy among 73 patients with carcinoma of the distal esophagus, gastroesophageal junction (GEJ) and/or gastric cardia, was investigated in this retrospective study. Results indicate that among the 30 patients with recurrence, distant sites (n = 24) were more common than local sites (n = 6) and this difference was statistically significant (P = 0.001). Lungs and liver were the most common sites of first recurrence, 51%, while mediastinal nodes were the sites of first recurrence in 6% of cases. Twenty patients (27.4%) had pathologic complete response, 20 patients (27.4%) had disease downstaging, 17 patients (23.3%) had no response, and 12 (16.4%) had disease progression. Time to first recurrence was significantly reduced in patients with pathologic stage III disease (P = 0.044). Patients receiving 50 Gy of neoadjuvant radiotherapy had lower rates of recurrence than patients receiving 45 Gy (P = 0.025). Five-year disease-free survival and overall survival were 61.6% and 60.3%, respectively. Since mediastinal failure rates were significantly lower than distant failure rates in this study, it appears that aggressive mediastinal control at the time of esophagectomy in patients with carcinoma of the distal esophagus, GEJ and/or gastric cardia, who have received neoadjuvant chemoradiotherapy, is unnecessary. Furthermore, since pathologic stage of disease is significantly associated with disease recurrence, more efforts should be made to improve systemic therapy prior to and/or after resection.

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