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Background: The survival outcomes of patients with esophageal squamous cell carcinoma (ESCC) after open or thoracoscopic upfront esophagectomy remained unclear., Objective: The aim of this retrospective study was to compare overall survival between open and thoracoscopic esophagectomy for ESCC patients without neoadjuvant chemodatiotherapy (CRT)., Methods: The Taiwan Cancer Registry was investigated for ESCC cases from 2008 to 2016. We enrolled 2053 ESCC patients receiving open (n = 645) or thoracoscopic (n = 1408) upfront esophagectomy. One-to-two propensity score matching between the two groups was performed. Stage-specific survival was compared before and after propensity score matching. Univariate analysis and multivariate analysis were used to identify risk factors., Results: After one-to-two propensity score matching, a total of 1299 ESCC patients with comparable clinic-pathologic features were identified. There were 433 patients in the open group and 866 patients in the thoracoscopic group. The 3-year overall survival of matched patients in the thoracoscopic group was better than that of matched patients in the open group (58.58% vs 47.62%, P = 0.0002). Stage-specific comparisons showed thoracoscopic esophagectomy is associated with better survival than open esophagectomy in patients with pathologic I/II ESCC. In multivariate analysis, surgical approach was still an independent prognostic factor before and after one-to-two propensity score matching., Conclusion: This propensity-matched study revealed that thoracoscopic esophagectomy could provide better survival than open esophagectomy in ESCC patients without neoadjuvant CRT., Competing Interests: The authors report no conflicts of interest and no funding sources. Disclosures: B-Y.W., C-H.L., S-C.W., and H-S.C. have no conflict of interest or financial ties to disclose., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: The goal of this study was to investigate the overall survival between open and thoracoscopic oesophagectomy in patients with oesophageal squamous cell carcinoma (ESCC) undergoing neoadjuvant chemoradiotherapy (NCRT)., Methods: The Taiwan Cancer Registry was queried for ESCC from 2008 to 2016. We enrolled 2250 patients with ESCC receiving NCRT plus open (n = 487) or thoracoscopic (n = 1763) oesophagectomy. One-to-two propensity score matching between open and thoracoscopic oesophagectomy was performed. Overall survival was compared between the 2 groups before and after propensity score matching. Univariable analysis and multivariable analysis were performed to identify prognostic factors., Results: After one-to-two propensity score matching, 353 patients were in the open group and 706 patients were in the thoracoscopic group. The 3-year overall survival rates for matched patients treated with open or thoracoscopic oesophagectomy were similar (39.18% vs 44.33%, p = 0.11). Better overall survival was associated with thoracoscopic oesophagectomy for the patients in the y-pathological complete response stage (pCR) (57.26% vs 65.19%, p = 0.045), y-pathological III stage (12.78% vs 22.31%, p = 0.028) and y-pathological T0N+ stage (15.79% vs 41.01%, p = 0.010). In multivariable analysis, surgical approach was an independent prognostic factor only before propensity score matching. After matching, surgical approach was not an independent prognostic factor., Conclusions: This propensity-matched study demonstrated that open and thoracoscopic oesophagectomies are associated with similar long-term survival in patients with ESCC undergoing NCRT. Stage-specific comparisons showed that thoracoscopic oesophagectomy is associated with better survival than open oesophagectomy in patients with the pathological complete response, y-pathological III and y-pathological T0N+ stages and with similar survival in y-pathological I/II patients., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: For patients with locoregional esophageal squamous cell carcinoma (ESCC), survival outcomes among neoadjuvant chemoradiotherapy followed by operation (nCRT-OP), definitive chemoradiotherapy (dCRT), and esophagectomy alone remain controversial., Patients and Methods: Information from the 2008-2016 Taiwan Cancer Registry was used. A total of 7637 cT1b-4, N0/+, M0 ESCC patients receiving nCRT-OP (n = 1955), dCRT (n = 4122), or esophagectomy alone (n = 1560) were included. Propensity score matching was performed to balance clinical variables among the three groups. Stage-specific overall survival was compared before and after propensity score matching. Univariable and multivariable analyses were performed to identify prognostic factors., Results: Propensity score matching resulted in 1407 cases for comparison. The 5-year overall survival rates for matched patients treated via dCRT, nCRT-OP, and esophagectomy alone were 19.77%, 31.23%, and 30.52%, respectively (p < 0.001). On multivariable analysis, treatment modality was still an independent prognostic factor both before and after propensity score matching. nCRT-OP and esophagectomy alone were associated with significantly better overall survival than dCRT for locoregional ESCC patients., Conclusions: This propensity-matched study revealed that nCRT-OP and esophagectomy provided better survival than dCRT in cT1b-4, N0/+, M0 ESCC patients., (© 2021. Society of Surgical Oncology.)

Background: This study compared survival between definitive chemoradiotherapy (CRT) and esophagectomy alone among patients with locoregional esophageal squamous cell carcinoma (SCC)., Methods: Data were obtained from the Taiwan Cancer Registry between 2008 and 2014. Included were 5,487 patients with clinical I, II, or III esophageal SCC who received definitive CRT or esophagectomy alone. Patients were stratified according to clinical stage. Overall survival was compared between patients treated with definitive CRT versus esophagectomy alone, and between patients in the three different clinical stages. Propensity-matched analysis along with univariate and multivariate analysis were performed., Results: Treatment was with definitive CRT in 4,251 patients (77.50%) and esophagectomy alone in 1,236 (22.50%). Propensity score matching produced 1,020 patients for comparison. The overall survival rates at 1, 2, and 3 years were 60.92%, 34.96%, and 26.14%, respectively, for propensity-matched patients treated with definitive CRT and were 71.15%, 56.50%, and 46.17%, respectively, for propensity-matched patients treated with esophagectomy alone (p < 0.001). Multivariate analysis showed treatment strategy was an independent prognostic factor. Esophagectomy alone was associated with significantly better overall survival than definitive CRT for patients with clinical stage I/II disease. There was no survival risk difference between definitive CRT and esophagectomy only for patients with clinical stage III disease., Conclusions: Esophagectomy alone could provide better survival than definitive CRT for patients with clinical stage I/II esophageal SCC. However, definitive CRT and esophagectomy yield similar overall survival rates in clinical stage III patients., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The benefits of neoadjuvant chemoradiation (NCRT) compared to upfront esophagectomy (UE) in esophageal squamous cell carcinoma (ESCC) is controversial. Our purpose was to determine whether clinical stages based on the 8th edition American Joint Committee on Cancer Tumor-Node-Metastasis staging system could guide treatment decision., Methods: Data from 2503 patients with clinical stages II and III ESCC diagnosed between 2008 and 2014 were obtained from a nationwide database. Propensity score matching was used to identify well-balanced pairs of patients. Cox proportional hazards regression and log-rank test were used in the survival analysis. The outcomes of patients receiving "NCRT followed by surgery" or "UE" strategies were compared., Results: The treatment modality (UE or NCRT) was not a prognostic factor in clinical stage II ESCC (HR: 0.97; p = 0.778). In contrast, the UE group demonstrated a significantly worse outcome compared with the NCRT group in clinical stage III ESCC (HR: 1.39; p < 0.001). After matching, patients who underwent UE for clinical stage II ESCC had median survival/3-year overall survival (OS) rates of 27.8 months/39.2% compared with 32.7 months/49.8% in the NCRT group (p = 0.508). The patients who underwent UE for clinical stage III ESCC had median survival/3-year OS rates of 17.9 months/28.2% in the UE group compared with 24.0 months/41.8% in the NCRT group (p < 0.001)., Conclusions: Our data suggest that NCRT strategy improved survival compared with UE in clinical stage III ESCC but not in clinical stage II tumors.

Background: Current esophageal treatment guidelines suggest that, when more than 15 lymph nodes are detected, dissection should be done as the minimum requirement for staging in esophageal squamous cell carcinoma (ESCC) patients undergoing esophagectomy without induction chemoradiotherapy (CRT). However, for neoadjuvant CRT, there is limited information. We sought to clarify the role of lymphadenectomy in ESCC patients with and without neoadjuvant CRT., Patients and Methods: Data on 3156 ESCC patients receiving esophagectomy with (group 1, n = 1399) and without (group 2, n = 1757) neoadjuvant CRT between 2008 and 2014 were collected from a national cancer registry in Taiwan. The impact of the resected lymph nodes on overall survival was assessed according to pathologic stages. A Cox regression model was used to identify prognostic factors for overall survival., Results: Five-year overall survival rates were 35.6% for the entire group, 30.32% for group 1, and 39.55% for group 2 (p < 0.0001 for group 1 vs group 2). The best cutoff value was 21 lymph nodes in both group 1 and group 2. In group 1, the independent prognostic factors included age ≥ 54 years, clinical N status, y-pathologic T, y-pathologic N, y-pathologic stage, grade, location, margin status, esophagectomy (thoracoscopic vs open), and number of total resected lymph nodes (≤ 21 vs > 21). For group 2, the independent prognostic factors were gender, clinical stage, pathologic T, pathologic N, tumor length, grade, and margin status., Conclusions: Extent of lymphadenectomy was associated with survival in patients with neoadjuvant CRT followed by esophagectomy. The optimum lymphadenectomy should be modulated by pathologic stage.

Background: The eighth edition of the American Joint Committee on Cancer Tumor-Node-Metastasis staging system separates classifications for the clinical (c), pathologic (p), and postneoadjuvant pathologic (yp) stages. We aimed to evaluate its application in patients with esophageal squamous cell carcinoma (ESCC)., Methods: Patient data were obtained from the Taiwan Cancer Registry database. Patients who underwent esophagectomy for c stage I to III ESCC were included for survival analysis., Results: Data of 3,399, 1,805, and 1,594 patients were included for c, p, and yp staging, respectively. The 3-year overall survival (OS) rates for c stage I, II, and III were 67.4%, 46.7%, and 38.4%, respectively. The 3-year OS rates for p stage I, II, III, and IV were 70.7%, 49.8%, 30.8%, and 10.6%, respectively. The 3-year OS rates for yp stage I, II, III, and IV were 59.4%, 37.8%, 27.6%, and 3.7%, respectively. Survival curve analysis demonstrated a robust discriminatory capability and monotonicity of gradients of the new system. However, yp stage I was observed in a heterogeneous group of patients with substantial survival differences. Meanwhile, patients in the ypT0 N0 stage had a 5-year OS rate of 52.1%, which was equivalent to that of patients with p stage I (54.5%). The 5-year OS rate of patients in the ypTis-2N0 was 39.1%, which was equivalent to that of patients in p stage II (40.1%)., Conclusions: The present study serves as an external validation of the newly released staging system in the prognostication of patients with ESCC and suggests subgrouping of the yp stage I into ypT0 N0 and non-ypT0 N0 in the future., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Adjuvant chemoradiation is reported to have a survival benefit for esophageal squamous cell carcinoma (ESCC). We evaluated the "upfront surgery and pathological stage-based adjuvant chemoradiation" strategy, in which adjuvant therapy is guided by pathological stage, in locally advanced ESCC. Data from 2976 clinical stage II/III ESCC patients, including 1735 in neoadjuvant chemoradiation and 1241 in upfront surgery groups, were obtained from a nationwide database. Patients in the upfront surgery group were further categorized into the "upfront surgery and pathological stage-based adjuvant chemoradiation" and "upfront surgery only" groups. The 3-year overall survival (OS) rates in the "neoadjuvant chemoradiation", "upfront surgery and pathological stage-based adjuvant chemoradiation", and "upfront surgery only" groups were 41.5%, 45.8%, and 28.5%, respectively. In propensity score matched patients, the 3-year OS rate was 41.7% in the neoadjuvant chemoradiation group, compared to 35.6% in the "upfront surgery and pathological stage-based adjuvant chemoradiation" group (p = 0.147), and 20.3% in the "upfront surgery only" group (p < 0.001). No survival difference was observed between the "neoadjuvant chemoradiation followed by surgery" protocol and the "upfront surgery and pathological stage-based adjuvant chemoradiation" strategy.

Objectives: Although preoperative chemoradiation followed by surgery has been recognized as an efficient strategy for esophageal cancer treatments, several studies demonstrate survival benefits of postoperative chemoradiation for those undergoing upfront resection. The optimal sequence of surgery and chemoradiation remains unclear., Methods: Data of 1647 patients with clinical stage II/III esophageal squamous cell carcinoma (ESCC), including 1245 receiving preoperative chemoradiation followed by esophagectomy (pre-OP CRT group) and 402 receiving primary esophagectomy followed postoperative chemoradiation (post-OP CRT group), were obtained from a nationwide database. Propensity score matching identified 286 well-balanced pairs for outcome comparison., Results: In matched patients, the 3-year overall survival (OS) rates/median survival were not significantly different between the 2 groups (44.0% 3-year OS/26.0 months; 95% confidence interval [CI], 18.9-89 38.0 months) in the pre-OP CRT group, versus 37.9% 3-year OS/23.5 months (95% CI, 18.5-29.9 months) in the post-OP CRT group, P = .3152). The 3-year disease-free survival rates (DFS)/median survival after surgery were 38.7% 3-year DFS/16.7 months (95% CI, 11.9-29.6 months) in the pre-OP CRT group, compared with 30.2% 3-year DFS/10.4 months (95% CI, 7.6-14.0 months) in the post-OP CRT group (P = .0674). In patients who had complete resection, the freedom from recurrence rate at 1 year after surgery was 74.8% and 67.6% in pre-OP CRT and post-OP CRT groups, respectively (P = .2696). In the multivariable analysis, treatment modality (pre- or post-OP CRT) was not a significant factor for OS (P = .258) or disease-free survival (P = .521)., Conclusions: Similar outcome can be achieved with postoperative chemoradiotherapy compared with preoperative chemoradiotherapy in patients with locally advanced ESCC. There is little difference between these 2 strategies., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Few data are currently available on the factors associated with survival in oesophageal cancer patients who achieve pathological complete response (pCR) after chemoradiotherapy (CRT). Using a nationwide database, we investigated the predictors of survival in this patient group., Methods: Data were retrieved from the Taiwan Cancer Registry to identify patients with oesophageal squamous cell carcinoma (OSCC) who achieved pCR after CRT followed by oesophagectomy between 2008 and 2013. The median number of dissected nodes (20) was used as the cut-off to classify the extent of lymph node dissection (LND). Tumour location was defined according to the seventh edition of the American Joint Committee on Cancer staging system. Cox proportional hazard regression analyses were used to identify factors associated with survival., Results: Of the 1103 patients who underwent CRT followed by surgery, 319 (28.9%) achieved pCR. Thirty- and 90-day mortality rates were 3.5 and 4.7%, respectively. The 3-year overall survival rate was 55.9%. Multivariate Cox survival analysis identified age ≥55 years [hazard ratio (HR): 1.72, 95% confidence interval (CI): 1.07 to 2.78, P = 0.025], an LND number of <20 (HR: 1.62, 95% CI: 1.01 to 2.61, P = 0.047) and lesions located in the upper third (HR: 2.35, 95% CI: 1.18 to 4.65, P = 0.015) as adverse prognostic factors for survival in pCR patients., Conclusions: Patient age ≥55 years, upper third lesions and an LND number of <20 are adverse prognostic factors in OSCC patients who achieve pCR following CRT. High-risk patients should be strictly followed., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: We aim to evaluate the prognostic value of metastatic lymph node number (MLN) and ratio (MLR) in oesophageal squamous cell carcinoma (OSCC) patients with or without neoadjuvant chemoradiation., Methods: Two thousand one hundred and fifty-one OSCC patients receiving oesophagectomy with (n = 850) or without (n = 1301) neoadjuvant chemoradiation were included. The MLN was categorized into 0 (N0), 1-2 (N1), 3-6 (N2) and more than 7 (N3); the MLR was categorized into 0, 0-0.2 and >0.2. The prognostic value was evaluated with survival analysis using the Cox proportional hazards regression model and the Kaplan-Meier method., Results: In patients without neoadjuvant chemoradiation, the 3-year overall survival rates were 54.8, 34.4, 21.8 and 6.5% with MLN = 0, 1-2, 3-6 and more than 7, respectively (P < 0.001). The 3-year overall survival rates were 54.7, 31.2 and 14.2% with MLR = 0, 0-0.2 and more than 0.2, respectively (P < 0.001). In patients with neoadjuvant chemoradiation, the 3-year overall survival rates were 49.0, 28.4, 12.5 and 0.0% with MLN = 0, 1-2, 3-6 and more than 7, respectively (P < 0.001). However, the survival curves of MLN = 3-6 and MLN ≥7 overlapped on the Kaplan-Meier plots. In contrast, MLR demonstrated good ability to show the survival differences on the Kaplan-Meier plots. The 3-year overall survival rates were 48.9, 27.3 and 0.0% with MLR = 0, 0-0.2 and more than 0.2, respectively (P < 0.001)., Conclusions: Both MLN and MLR were significant prognostic factors in OSCC patients regardless of neoadjuvant chemoradiation. But in patients with neoadjuvant chemoradiation, the survival rates were similar between ypN2 and ypN3 patients, suggesting that there was no necessity of separating patients into ypN2 and ypN3 stages., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The role of adjuvant chemoradiation in esophageal cancer has been underestimated in the literature. This study was undertaken to determine whether adjuvant chemoradiation improves survival compared with surgery alone., Methods: Data of 1095 esophageal squamous cell carcinoma (ESCC) patients, including 679 in surgery alone group (group 1) and 416 in surgery followed adjuvant chemoradaition group (group 2), were obtained from the Taiwan Cancer Registry database. Propensity score matching (PSM) analysis was used to identify 147 well-balanced patients in each group for overall survival comparison., Results: After PSM, the 3-year survival rates and median survival were 44.9% and 27.2 (95% confidence interval [CI]: 17.6-40.3) months in group 2, which is significantly higher than that in group 1 (28.1% and 18.2 [95% CI: 14.3-24.5] months, P = 0.0043). In the multivariate survival analysis, pT3/4 stage (Hazard Ratio [HR]: 2.03, 95% CI: 1.38-2.97, P < 0.001), pN+ stage (HR: 1.83, 95% CI: 1.31-2.57, P = 0.0004), tumor length more than 32 mm (HR: 1.93, 95% CI: 1.33-2.79, P < 0.001), R1/2 resection (HR: 1.75, 95% CI: 1.15-2.66, P = 0.009), and adjuvant chemoradiation (HR: 0.57, 95% CI: 0.42-0.78, P < 0.0001) were independent prognostic factors. Subgroup analysis suggested patients with pT3/4 stage, pN+ stage tumors, larger tumor size, poorly differentiated tumors, and R1/2 resections were more likely to demonstrate survival benefit from adjuvant chemoradiation., Conclusions: Compared with surgery alone, adjuvant chemoradiation provides a survival benefit to ESCC patients, especially those with pT3/4 stage, N+ tumors, larger tumor size, poorly differentiated tumors, and R1/2 resections.

Background: Few data are available on the survival outcomes of patients with esophageal squamous cell carcinoma who achieve complete response at the primary site but have residual nodal metastases after chemoradiotherapy. We sought to assess the survival of esophageal squamous cell carcinoma patients with ypT0 N+ disease., Methods: Esophageal squamous cell carcinoma patients treated with chemoradiotherapy and esophagectomy were identified from the Taiwan Cancer Registry between 2008 and 2013. We compared the clinical and survival data of ypT0 N+ and ypT0 N0 patients. The median number of dissected nodes (n = 20) was used as the cutoff to classify the extent of lymph node dissection (LND). Survival data were analyzed with the Kaplan-Meier method and Cox proportional hazards regression models., Results: The study included 369 ypT0 patients (50 ypT0 N+ [13.6%] and 319 ypT0 N0 [86.4%]). The 3-year overall survival was significantly lower in ypT0 N+ patients (30.1%) than in ypT0 N0 patients (55.9%, p < 0.001). Multivariate analysis showed that a higher number of positive lymph nodes (ypN2/N3 vs ypN1) was a strong adverse prognostic factor (hazard ratio, 3.76; p = 0.011) in ypT0 N+ patients. The extent of LND was identified as an independent predictor of survival in patients with ypT0 N0 disease (low vs high; hazard ratio, 1.49; p = 0.045). A stepwise decrease in 3-year overall survival rates was observed in the following groups: ypT0 N0 with high LND (61.2%), ypT0 N0 with low LND (50.3%), and ypT0 N+ (30.1%, p < 0.001)., Conclusions: At least 13.6% of ypT0 patients have lymph node metastases, which carry adverse prognostic implications. The number of positive nodes is the most important prognostic factor in this group., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The optimal treatment modality for locoregional esophageal squamous-cell carcinoma (ESCC) is still undetermined. This study investigated the treatment modalities affecting survival of patients with ESCC in Taiwan.Data on 6202 patients who underwent treatment for locoregional esophageal squamous-cell carcinoma during 2008 to 2012 in Taiwan were collected from the Taiwan Cancer Registry. Patients were stratified by clinical stage. The major treatment approaches included definitive chemoradiotherapy, preoperative chemoradiation followed by esophagectomy, esophagectomy followed by adjuvant therapy, and esophagectomy alone. The impact of different treatment modalities on overall survival was analyzed.The majority of patients had stage III disease (n = 4091; 65.96%), followed by stage II (n = 1582, 25.51%) and stage I cancer (n = 529, 8.53%). The 3-year overall survival rates were 60.65% for patients with stage I disease, 36.21% for those with stage II cancer, and 21.39% for patients with stage III carcinoma. Surgery alone was associated with significantly better overall survival than the other treatment modalities for patients with stage I disease (P = 0.029) and was associated with significantly worse overall survival for patients with stage III cancer (P < 0.001). There was no survival risk difference among the different treatment methods for patients with clinical stage II disease.Multimodality treatment is recommended for patients with stage II-III esophageal squamous-cell carcinoma. Patients with clinical stage I disease can be treated with esophagectomy without preoperative therapy., Competing Interests: The authors have no funding and conflicts of interest to disclose.

While preoperative chemoradiation followed by surgery (pre-OP CRT) has been widely applied in the treatment of patients with esophageal cancer, some studies have shown a survival benefit of postoperative chemoradiation (post-OP CRT). The optimal combination of multimodality therapy and the sequence of surgery and chemoradiation for esophageal cancer remain to be investigated. A total of 1385 patients with clinical stage II and III esophageal squamous cell carcinoma (ESCC) were included. On the basis of the sequence of surgery and chemoradiation, the patients were grouped as follows: preoperative chemoradiation followed by surgery (pre-OP CRT+S), surgery alone (S), and surgery followed by postoperative chemoradiation (S+post-OP CRT). Propensity score matching analysis was used to identify 78 well-balanced patients in each group for outcome comparison.In all, 753, 339, and 293 patients were in the pre-OP CRT+S, S, and S+post-OP CRT groups, respectively. Before matching, no differences were observed in the overall survival among the patients in these 3 groups (P = 0.422). After matching, both the pre-OP CRT+S and S+post-OP CRT groups were significantly associated with a better survival compared with the S group (pre-OP CRT+S vs. S: P < 0.001; S+post-OP CRT vs. S: P = 0.005). In contrast, the survival was similar between the pre-OP CRT+S and S+post-OP CRT groups (P = 0.544). In the subgroup analysis, patients with clinical T3/4 stage tumors or those with a tumor size greater than 5 cm were more likely to demonstrate an overall survival benefit from pre-OP CRT compared with post-OP CRT. Both pre-OP CRT and post-OP CRT demonstrated a survival benefit compared with surgery alone, which indicates the importance of trimodality therapy in patients with clinical stage II/III ESCC. However, no survival difference was observed among patients in the pre-OP CRT+S and S+post-OP CRT groups, which suggests that the sequence of surgery and chemoradiation may be irrelevant to the outcome.

Background: The optimal interval between chemoradiotherapy (CRT) and esophagectomy in patients with esophageal squamous cell carcinoma is still undetermined. The aim of this study was to evaluate the association between different treatment intervals and clinical impact, including perioperative outcome and long-term survival., Methods: We retrospectively reviewed data from 665 patients with esophageal squamous cell carcinoma who underwent CRT and esophagectomy between 2008 and 2011 in Taiwan. Based on the interval between CRT and esophagectomy, patients were divided into group 1, less than 30 days; group 2, 30 to 59 days; group 3, 60 to 89 days; or group 4, 90 days or more. The impact of the treatment interval on perioperative outcomes and overall survival were assessed. A Cox regression model was used to identify prognostic factors for overall survival., Results: There were 90 patients in group 1, 385 patients in group 2, 141 patients in group 3, and 49 patients in group 4. The 30-day surgical mortality rate was 5.6%, 2.9%, 1.4%, and 10.2% for groups 1, 2, 3, and 4, respectively (p = 0.018). The 90-day surgical mortality rate was 12.2%, 6.8%, 5.7%, and 18.4% for groups 1, 2, 3, and 4, respectively (p = 0.012). The differences between surgical margin positivity rates were also significant: 2.2% in group 1, 4.9% in group 2, 9.2% in group 3, and 12.2% in group 4 (p = 0.032). The treatment interval was not associated with the complete response and the overall survival., Conclusions: Although early operation (less than 30 days) is associated with reduced rates of surgical margin positivity, the potential benefits appear to be outweighed by the significant increase in postoperative mortality. The surgical timing that optimizes both mortality and surgical margin positivity requires further study., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Aim: To study the "hospital type-outcome" and "volume-outcome" relationships in patients with esophageal cancer who receive non-surgical treatments., Methods: A total of 6106 patients with esophageal cancer diagnosed between 2008 and 2011 were identified from a national population-based cancer registry in Taiwan. The hospital types were defined as medical center and non-medical center. The threshold for high-volume hospitals was based on a median volume of 225 cases between 2008 and 2011 (annual volume, >56 cases) or an upper quartile (>75%) volume of 377 cases (annual volume>94 cases). Cox regression analyses were used to determine the effects of hospital type and volume outcome on patient survival., Results: A total of 3955 non-surgically treated patients were included in the survival analysis. In the unadjusted analysis, the significant prognostic factors included cT, cN, cM stage, hospital type and hospital volume (annual volume, >94 vs ≤94). The 1- and 3-year overall survival rates in the non-medical centers (36.2% and 13.2%, respectively) were significantly higher than those in the medical centers (33.5% and 11.3%, respectively; P=0.027). The 1- and 3-year overall survival rates in hospitals with an annual volume of ≤94 (35.3% and 12.6%, respectively) were significantly higher than those with an annual volume of >94 (31.1% and 9.4%, respectively; P=0.001). However, in the multivariate analysis, the hospital type was not statistically significant. Only cT, cN, and cM stages and hospital volume (annual volume>94 vs ≤94) were independent prognostic factors., Conclusion: Whether the treatment occurs in medical centers is not a significant prognostic factor. High-volume hospitals were not associated with better survival rates compared with low-volume hospitals.

The prognostic value for the post-chemoradiation therapy (CRT) pathologic stage is uncertain. The purpose of this study was to compare the pathologic stage in patients undergoing esophagectomy with and without preoperative CRT for esophageal squamous cell carcinoma (ESCC). This study retrospectively reviewed the data from 2151 patients with ESCC who underwent esophagectomy with or without preoperative CRT between 2008 and 2011 in Taiwan. Patients were divided into 2 groups. Group A consisted of patients treated with primary surgery without prior treatments (n=1301), and group B consisted of patients receiving preoperative CRT followed by esophagectomy (n=850). In group A, 679 patients received surgery alone, 92 received postoperative chemotherapy, 416 received postoperative chemoradiation therapy, and 114 received postoperative radiation therapy. In group A, the 3-year survival rates by pathologic stage were 82.2% for stage 0, 67.6% for stage I, 50.7% for stage II, 21.5% for stage III, and 14.8% for stage IV (P<.001). In group B, the 3-year survival rates of post-CRT pathologic stages 0, I, II, III, and IV were 59.4%, 46.0%, 40.3%, 19.1%, and 8.2%, respectively (P<.001). In multivariate analysis, the pathologic T, N, and M were all independent prognostic factors in both group A (esophagectomy alone) and B (CRT plus esophagectomy). The current, 7th edition of the esophageal TNM staging system could adequately stratify prognostic groups in patients with squamous cell carcinoma who were treated with preoperative CRT and esophagectomy., (Copyright © 2014 by the National Comprehensive Cancer Network.)

Objectives: Previous studies have shown that patients who undergo oesophageal cancer surgery in high-volume hospitals have lower postoperative mortality rates. However, the impact of hospital volume on long-term survival is controversial., Methods: We identified 2151 patients who were diagnosed with oesophageal cancer between 2008 and 2011 from a national population-based cancer registry in Taiwan. High-volume hospitals were defined as those performing more than 86 oesophagectomies during that period (22 cases/year). Patients were stratified by whether they received preoperative chemoradiation. Cox regression analyses were used to determine the survival impact of hospital volume., Results: The 3-year overall survival rates after oesophagectomies were 44.9% in high-volume hospitals, compared with 40.2% in low-volume hospitals (P = 0.002). For patients who received preoperative chemoradiation (n = 850), the 1- and 3-year overall survival rates were 74.7 and 36.8%, respectively, in high-volume hospitals, compared with 73.5 and 42.6%, respectively, in low-volume hospitals (P = 0.333). For patients who did not receive preoperative chemoradiation (n = 1301), the 1- and 3-year overall survival rates were 78.1 and 50.0%, respectively, in high-volume hospitals, compared with 67.9 and 38.8%, respectively, in low-volume hospitals (P < 0.001). Multivariate analysis showed that hospital volume, resection margin, cT, pT and pN stages are significant independent prognostic factors., Conclusions: Overall survival rate of patients who undergo oesophagectomies without preoperative chemoradiation at high-volume hospitals is significantly higher than at low-volume hospitals. However, there was no significant correlation between hospital volume and long-term outcome in patients who received preoperative chemoradiation., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)