Neoadjuvant chemotherapy and surgery for esophageal adenocarcinoma: prognostic value of circumferential resection margin and stratification of N1 category.

BACKGROUND: In the UK, it is standard practice to treat esophageal adenocarcinoma with neoadjuvant chemotherapy (no radiation) and surgery. We examined the prognostic value of the status of the circumferential resection margin (CRM) and stratification of the N1 category into 1-4 nodes or > or = 5 nodes.
METHODS: Between 2000 and 2006, 105 patients with radiologically staged T3, T4 or N1 esophageal adenocarcinoma had preoperative chemotherapy. One hundred and one patients had an Ivor Lewis operation with two-field lymphadenectomy, three had a transhiatal operation and one had a three-incision operation. CRM was assessed by painting the specimen with India ink and transverse sections at 5-10 mm intervals. The CRM was considered positive (CRM+) if malignant cells were within 1 mm of the inked margin.
RESULTS: There were 87 men. The median age was 61 years (range 37-81 years). Median lymph node yield was 28 (4-77); 86 patients (83%) had > or = 18 nodes. Seventy-four patients (70%) had N1 disease, with 1-4 involved nodes in 41 patients (39%) and > or = 5 nodes in 33 patients (31%). The CRM was positive in 38 patients (36%). On multivariate analysis, nodal metastasis [N0 versus N1; hazard ratio (HR) 3.3, 3-year survival 80% versus 40%; P = 0.004], CRM status (CRM- versus CRM+: HR 2.6, 3-year survival 64% versus 26%; P = 0.002) and vascular invasion (V0 versus V1: HR 2.2, 3-year survival 67% versus 39%; P = 0.014) retained independently significant prognostic value. N1 patients with 1-4 nodes had longer survival than those with > or = 5 nodes (56% versus 21%; P < 0.001).
CONCLUSIONS: CRM involvement and stratification of the N1 category are independent prognostic factors after multimodal therapy for esophageal adenocarcinoma.