LETTER TO THE EDITOR Poorer Survival for Stage IIa Patients After Minimally Invasive Esophagectomy To the Editor: e read with great interest the article from a leading center for totally minimally invasive esophagectomy (MIE) and would like to congratulate Luketich and colleagues1 on their excellent short-term outcomes. No other center can compete in terms of experience and case volume with MIE. Other units practicing MIE must use these results as a benchmark, although without such case volume, similar results will be difficult to reproduce in other centers. The authors have refined their techniques over time with acceptable morbidity and low mortality. The in-hospital mortality was 2.8%, with an even lower value of 1.7% for the most recent 500 cases. As indicated in the “Discussion” section following the article, this in-hospital figure is a more accurate reflection of mortality than 30-day mortality. We wish to pose 2 specific questions. First, the Kaplan-Meier plot for overall survival excludes any patients who received neoadjuvant therapy. Does it combine both patients with adenocarcinoma and squamous cell carcinoma? It is now recognized that these 2 cancers have different etiology, behavior, and response to treatment and consequently offer differing prognosis.2,3 It would therefore be important to present results for each appearing as separate plots. Second, how do the authors explain the apparent poor prognosis of patients with stage IIa (TNM 6th edition) disease? The plot illustrates that survival for this group of patients, who were node-negative on histology, was worse than patients with stage IIb disease. Furthermore, the median overall survival for stage IIa disease was lower than one would expect. Although the groups were not matched, Northern Oesophago-Gastric Cancer Unit’s results for an open, 2-phase subtotal esophagectomy with 2-field lymph node dissection from 1992 to 2011 had a median overall survival of 109 months for stage IIa disease treated with surgery alone (95% confidence interval, 49– 169) (unpublished data). The recent publication from The Netherlands similarly demonstrated survival advantages for stage IIa over
W
Disclosure: The authors declare no conflicts of interest or source of funding. C 2014 Wolters Kluwer Health, Inc. All Copyright rights reserved. ISSN: 0003-4932/14/26202-e0045 DOI: 10.1097/SLA.0000000000000532
IIb patients in a cohort of predominantly patients with adenocarcinoma treated with transhiatal resection.4 Do the authors consider that with the median lymph node yield of 21 (interquartile range, 15–29) these stage IIa patients may have been understaged? The same radical resection must be performed, whether the technique used is minimally invasive or open, to afford the patient the greatest chance of cure from this aggressive cancer that spreads to lymph nodes early. We still firmly believe that MIE should be performed only if surgeons have received appropriate training in units such as Pittsburgh and have sufficient case volume to produce equivalent long-term oncological outcomes. Surgeons practicing MIE should start only in patients without preoperative evidence of nodal disease and only once sufficient skill and experience are obtained consider more challenging cases. Until that time, surgeons should still consider an open, radical resection as the gold standard of esophagectomy. Shajahan Wahed, MBChB (Hons), BSc (Hons), MRCS S. Michael Griffin, MD, MBBS, FRCS Northern Oesophago-Gastric Cancer Unit Royal Victoria Infirmary Newcastle upon Tyne, England [email protected]
REFERENCES 1. Luketich JD, Pennathur A, Awais O, et al. Outcomes after minimally invasive esophagectomy: review of over 1000 patients. Ann Surg. 2012;256:95–103. 2. Rice TW, Rusch VW, Ishwaran H, et al. Cancer of the esophagus and esophagogastric junction: data-driven staging for the seventh edition of the American Joint Committee on Cancer/International Union Against Cancer Cancer Staging Manuals. Cancer. 2010;116:3763–3773. 3. Siewert JR, Stein HJ, Feith M, et al. Histologic tumor type is an independent prognostic parameter in esophageal cancer: lessons from more than 1,000 consecutive resections at a single center in the Western world. Ann Surg. 2001;234:360–367; discussion 8–9. 4. Talsma K, van Hagen P, Grotenhuis BA, et al. Comparison of the 6th and 7th editions of the UICCAJCC TNM classification for esophageal cancer. Ann Surg Oncol. 2012;19:2142–2148.
Reply:
W
e read with interest the letter from Wahed and Griffin with regard to our article on the outcomes after minimally invasive esophagectomy (MIE) in more than 1000 patients.1 Wahed and Griffin raise Disclosure: The authors declare no conflicts of interest. 10.1097/SLA.0000000000000864
Annals of Surgery r Volume 262, Number 2, August 2015
many issues and highlight several important aspects regarding the performance of MIE, a complex surgical procedure. We agree that surgeons adopting MIE should start with less advanced disease and, as they gain experience and expertise, extend this approach to more locally advanced stages of carcinoma such as node-positive disease. With an increasing adoption of MIE in the United Kingdom and worldwide,2 it is important to carefully adopt new techniques with caution. In addition, there is now significant literature showing that improved outcomes after esophagectomy are associated with hospital volume, surgeon volume and training, and critical care expertise in the management of these patients.3,4–8 These factors should be taken into account when adopting any complex procedure including MIE. The primary aim of our article on MIE was to evaluate the perioperative outcomes after MIE in a large group of patients, and the secondary objective was to evaluate the differences between the perioperative outcomes after a McKeown-type, 3-incision MIE and Ivor Lewis MIE.1 The primary objective of the study was not to evaluate the oncological outcomes of MIE. The survival data presented in the article were limited and represented overall survival, not cancer-specific survival, and further follow-up is required to fully evaluate the oncological outcomes. These are areas of ongoing and future investigation. Wahed and Griffin have raised a few questions. With regard to their question on histology and staging, the AJCC 6th edition,9 does not distinguish between adenocarcinoma and squamous cell carcinoma, and therefore the survival curves presented in this article were not separated by esophageal cancer histological subtypes. The overwhelming majority of patients in our series had esophageal adenocarcinoma. We do agree that there are clearly differences between these 2 subtypes of esophageal cancer, and this has been reflected in the latest version of the staging system (AJCC 7th edition), where there are separate descriptors for stage classification for each histological subtype.3,10 Wahed and Griffin have also questioned the survival in the 2 subsets of stage II esophageal cancer: stage IIA and stage IIB esophageal cancer (as per the AJCC 6th edition). They refer to unpublished data from their center on the survival results in this subset of patients with esophageal cancer, and we look forward to the published results of their series. The authors also state that stage IIA survival was worse than stage IIB after MIE. We have carefully analyzed the results in this subgroup with the expertise of our biostatistical department and for uniformity have classified the stage II patients as per AJCC 6th edition for all patients (including www.annalsofsurgery.com | e45
Copyright © 2014 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 262, Number 2, August 2015
Griffin
reclassification of those after 2010). First, overall survival for stage IIA was similar to that of stage IIB, and both survival curves show widely overlapping confidence intervals. The survival in these 2 subsets was statistically similar, and the assumption that stage IIA survival was worse than stage IIB is incorrect. With regard to the issue of whether the extent of lymph node dissection accounts for staging differences, we have reviewed the lymph node resection in these patients and again did not find a significant difference between these cohorts. Analysis of the extent of lymphadenectomy in these cohorts showed an adequate lymph node dissection11 and that the lymph node count was nearly identical (median of 20 nodes resected for stage IIA and 21 nodes for stage IIB; mean 22 nodes resected in each group) with no significant differences. A review of other large series, with regard to stage II survival (AJCC 6th edition) shows similar trends. The largest singleinstitution series of open esophagectomy, by Orringer and colleagues,12 in more than 2000 patients describing an open transhiatal approach shows virtually overlapping survival curves for stage IIA and IIB disease in 481 patients with stage II esophageal cancer. The estimated 5-year overall survival in stage IIA patients was 27.8% and in those with stage IIB disease was 29.5%. A previous series from Orringer and colleagues13 comprising more than 1000 patients after transhiatal esophagectomy showed similar findings, with the estimated 5-year survival of 22% in patients with stage IIA disease and 29% in patients with stage IIB esophageal cancer. Swanson and colleagues,14 using a McKeown-type, 3-incision open esophagectomy, also reported similar findings. In the Swanson and colleagues series, 67 stage IIA patients had marginally worse survival than 30 stage IIB patients, with the estimated 3-year survival for stage IIA of 41% and stage IIB of 46%. Given the accrued knowledge since the formulation of the AJCC 6th edition revision, the apparent survival equality of patients with stage IIA and stage IIB esophageal cancer seen in our series is not atypical and has been reported in other large series of open esophagectomy as detailed earlier. Therefore, appearance of “poor prognosis” of stage IIA disease relative to stage IIB disease using the old AJCC 6th edition classification is not unusual at all. With regard to the lack of differences between the subgroups of stage II, there are several issues that merit further discussion regarding subgroup classification using the AJCC 6th edition staging system. In the AJCC 6th edition staging system, stage IIA included both T2 and T3 node-negative carcinomas, with no differences between the histologies. e46 | www.annalsofsurgery.com
The recent modification of the staging system, in AJCC 7th edition, recognized many limitations of the previous version, with significant changes to the staging system including separate classifications based on histology (adenocarcinoma vs squamous cell carcinoma) and revised criteria for stratification of subgroups. The survival in esophageal adenocarcinoma patients with T3 tumors is decreased even in node-negative patients when compared with node-negative patients with T2 tumors.15 Notably, in our series, a majority of patients who were classified as stage IIA were T3N0, and this may further explain the finding of similar survival in the stage IIA cohort. The AJCC 7th revision does not view stage T3N0M0 tumors with the same optimism as the 6th edition, where stage T3N0M0 tumors were classified as stage IIA. Indeed, according to the 7th revision, T3N0 adenocarcinomas are no longer classified as stage IIA but are reclassified as stage IIB. Even squamous cell tumors of grades 2 and 3 and of the upper or middle esophagus are now classified as stage IIB.10,15 One might expect patients with stage IIB disease to have worse survival, but the lack of a significant difference between these 2 subsets of stage II may again be related to the older AJCC 6 classification. Further analysis of survival outcomes using the new 7th edition staging system is needed. In addition, we and others have shown that the molecular staging of the tumor may predict better survival than that by the TNM classification (even after incorporating the AJCC 7th revision), and this is an area of active investigation to better stratify outcomes.16 The primary aim of our article evaluating the results of MIE was on perioperative outcomes and not the long-term survival results.1 In addition, the survival results presented are not cancer-specific survival results but rather the overall survival in the entire cohort. The patients who underwent esophagectomy with a minimally invasive approach included those with significant comorbidities. Nearly half of the patients in the series had a Charlson Comorbidity Index of greater than 3. These comorbidities may have accounted for noncancer deaths; however, this has not been analyzed separately and further work is required to address this in more detail. In addition, further follow-up is required to analyze the survival endpoints in more detail. Although we cannot make firm conclusions regarding survival based on this article, our early results did not show any significant difference in overall survival in the 2 subsets of stage II esophageal cancer in this cohort treated with MIE. In addition, the results of a meta-analysis comparing outcomes after esophagectomy with an open versus a minimally invasive approach show equivalent oncological results.17
Our MIE series comprising more than 1000 patients1 and the cumulative evidence from several large, open esophagectomy series discussed earlier lead us to suspect that in retrospect, it is not surprising that that the literature does not show consistent significant differences in survival between the subsets of stage II using the old AJCC 6th edition classification system. We thank Drs Wahed and Griffin for raising these important issues regarding the performance of a complex operation such as MIE and for giving us the opportunity to further elaborate on the impact of esophageal cancer staging on outcomes. We look forward to their results and also hope to present an update of our series incorporating the latest modifications in the staging system. Arjun Pennathur, MD Department of Cardiothoracic Surgery University of Pittsburgh Medical Center Pittsburgh, PA [email protected] William E. Gooding, MS Department of Biostatistics University of Pittsburgh Cancer Institute Pittsburgh, PA Katie S. Nason, MD Department of Cardiothoracic Surgery University of Pittsburgh Medical Center Pittsburgh, PA James D. Luketich, MD Department of Cardiothoracic Surgery University of Pittsburgh Pittsburgh, PA [email protected]
REFERENCES 1. Luketich JD, Pennathur A, Awais O. Outcomes after minimally invasive esophagectomy: review of over 1000 patients. Ann Surg. 2012;256:95– 103. 2. Lazzarino AI, Nagpal K, Bottle A, et al. Open versus minimally invasive esophagectomy. Trends of utilization and associated outcomes in England. Ann Surg. 2010;252:292–298. 3. Pennathur A, Gibson MJ, Jobe BA, et al. Oesophageal carcinoma. Lancet. 2013;381:400– 412. 4. Pennathur A, Luketich JD. Resection for esophageal cancer: strategies for optimal management. Ann Thorac Surg. 2008;85:S751–S756. 5. Pennathur A, Landreneau RJ, Luketich JD. Surgical aspects of the patient with high-grade dysplasia. Semin Thorac Cardiovasc Surg. 2005;17:326– 332. 6. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346:1128– 1137. 7. Dimick JB, Goodney PP, Orringer MB, et al. Specialty training and mortality after esophageal cancer resection. Ann Thorac Surg. 2005;80:282–286. 8. Dimick JB, Pronovost PJ, Heitmiller RE, et al. Intensive care unit staffing is associated with decreased length of stay, hospital cost, and
C 2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2014 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 262, Number 2, August 2015
complications after esophageal resection. Crit Care Med. 2001;29:904–905. 9. American Joint Committee on Cancer. AJCC Cancer Staging Manual. 6th ed. New York: Springer; 2002. 10. Esophagus and esophagogastric junction. In: Edge SB, American Joint Committee on Cancer, eds. AJCC Cancer Staging Manual. 7th ed. New York: Springer; 2010:103–115. 11. Rizk N, Venkatraman E, Park B, et al. The prognostic importance of the number of involved lymph nodes in esophageal cancer: implications for revisions of the American Joint Committee on Cancer staging system. J Thorac Cardiovasc Surg. 2006;132:1374–1381.
12. Orringer MB, Marshall B, Chang AC, et al. Two thousand transhiatal esophagectomies: changing trends, lessons learned. Ann Surg. 2007;246:363– 372; discussion 372–374. 13. Orringer MB, Marshall B, Iannettoni MD. Transhiatal esophagectomy: clinical experience and refinements. Ann Surg. 1999;230:392–400; discussion 400–403. 14. Swanson SJ, Batirel HF, Bueno R, et al. Transthoracic esophagectomy with radical mediastinal and abdominal lymph node dissection and cervical esophagogastrostomy for esophageal carcinoma. Ann Thorac Surg. 2001;72:1918–1924; discussion 1924–1925.
C 2014 Wolters Kluwer Health, Inc. All rights reserved.
Letter to the Editor
15. Rice TW, Rusch VW, Ishwaran H, et al. Cancer of the esophagus and esophagogastric junction: data-driven staging for the seventh edition of the American Joint Committee on Cancer/International Union Against Cancer Cancer Staging Manuals. Cancer. 2010;116:3763–3773. 16. Pennathur A, Xi L, Litle VR, et al. Gene expression profiles in esophageal adenocarcinoma predict survival after resection. J Thorac Cardiovasc Surg. 2013;145:505–512. 17. Sgourakis G, Gockel I, Radtke A, et al. Minimally invasive versus open esophagectomy: metaanalysis of outcomes. Dig Dis Sci. 2010;55:3031– 3040.
www.annalsofsurgery.com | e47
Copyright © 2014 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
W
Disclosure: The authors declare no conflicts of interest or source of funding. C 2014 Wolters Kluwer Health, Inc. All Copyright rights reserved. ISSN: 0003-4932/14/26202-e0045 DOI: 10.1097/SLA.0000000000000532
IIb patients in a cohort of predominantly patients with adenocarcinoma treated with transhiatal resection.4 Do the authors consider that with the median lymph node yield of 21 (interquartile range, 15–29) these stage IIa patients may have been understaged? The same radical resection must be performed, whether the technique used is minimally invasive or open, to afford the patient the greatest chance of cure from this aggressive cancer that spreads to lymph nodes early. We still firmly believe that MIE should be performed only if surgeons have received appropriate training in units such as Pittsburgh and have sufficient case volume to produce equivalent long-term oncological outcomes. Surgeons practicing MIE should start only in patients without preoperative evidence of nodal disease and only once sufficient skill and experience are obtained consider more challenging cases. Until that time, surgeons should still consider an open, radical resection as the gold standard of esophagectomy. Shajahan Wahed, MBChB (Hons), BSc (Hons), MRCS S. Michael Griffin, MD, MBBS, FRCS Northern Oesophago-Gastric Cancer Unit Royal Victoria Infirmary Newcastle upon Tyne, England [email protected]
REFERENCES 1. Luketich JD, Pennathur A, Awais O, et al. Outcomes after minimally invasive esophagectomy: review of over 1000 patients. Ann Surg. 2012;256:95–103. 2. Rice TW, Rusch VW, Ishwaran H, et al. Cancer of the esophagus and esophagogastric junction: data-driven staging for the seventh edition of the American Joint Committee on Cancer/International Union Against Cancer Cancer Staging Manuals. Cancer. 2010;116:3763–3773. 3. Siewert JR, Stein HJ, Feith M, et al. Histologic tumor type is an independent prognostic parameter in esophageal cancer: lessons from more than 1,000 consecutive resections at a single center in the Western world. Ann Surg. 2001;234:360–367; discussion 8–9. 4. Talsma K, van Hagen P, Grotenhuis BA, et al. Comparison of the 6th and 7th editions of the UICCAJCC TNM classification for esophageal cancer. Ann Surg Oncol. 2012;19:2142–2148.
Reply:
W
e read with interest the letter from Wahed and Griffin with regard to our article on the outcomes after minimally invasive esophagectomy (MIE) in more than 1000 patients.1 Wahed and Griffin raise Disclosure: The authors declare no conflicts of interest. 10.1097/SLA.0000000000000864
Annals of Surgery r Volume 262, Number 2, August 2015
many issues and highlight several important aspects regarding the performance of MIE, a complex surgical procedure. We agree that surgeons adopting MIE should start with less advanced disease and, as they gain experience and expertise, extend this approach to more locally advanced stages of carcinoma such as node-positive disease. With an increasing adoption of MIE in the United Kingdom and worldwide,2 it is important to carefully adopt new techniques with caution. In addition, there is now significant literature showing that improved outcomes after esophagectomy are associated with hospital volume, surgeon volume and training, and critical care expertise in the management of these patients.3,4–8 These factors should be taken into account when adopting any complex procedure including MIE. The primary aim of our article on MIE was to evaluate the perioperative outcomes after MIE in a large group of patients, and the secondary objective was to evaluate the differences between the perioperative outcomes after a McKeown-type, 3-incision MIE and Ivor Lewis MIE.1 The primary objective of the study was not to evaluate the oncological outcomes of MIE. The survival data presented in the article were limited and represented overall survival, not cancer-specific survival, and further follow-up is required to fully evaluate the oncological outcomes. These are areas of ongoing and future investigation. Wahed and Griffin have raised a few questions. With regard to their question on histology and staging, the AJCC 6th edition,9 does not distinguish between adenocarcinoma and squamous cell carcinoma, and therefore the survival curves presented in this article were not separated by esophageal cancer histological subtypes. The overwhelming majority of patients in our series had esophageal adenocarcinoma. We do agree that there are clearly differences between these 2 subtypes of esophageal cancer, and this has been reflected in the latest version of the staging system (AJCC 7th edition), where there are separate descriptors for stage classification for each histological subtype.3,10 Wahed and Griffin have also questioned the survival in the 2 subsets of stage II esophageal cancer: stage IIA and stage IIB esophageal cancer (as per the AJCC 6th edition). They refer to unpublished data from their center on the survival results in this subset of patients with esophageal cancer, and we look forward to the published results of their series. The authors also state that stage IIA survival was worse than stage IIB after MIE. We have carefully analyzed the results in this subgroup with the expertise of our biostatistical department and for uniformity have classified the stage II patients as per AJCC 6th edition for all patients (including www.annalsofsurgery.com | e45
Copyright © 2014 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 262, Number 2, August 2015
Griffin
reclassification of those after 2010). First, overall survival for stage IIA was similar to that of stage IIB, and both survival curves show widely overlapping confidence intervals. The survival in these 2 subsets was statistically similar, and the assumption that stage IIA survival was worse than stage IIB is incorrect. With regard to the issue of whether the extent of lymph node dissection accounts for staging differences, we have reviewed the lymph node resection in these patients and again did not find a significant difference between these cohorts. Analysis of the extent of lymphadenectomy in these cohorts showed an adequate lymph node dissection11 and that the lymph node count was nearly identical (median of 20 nodes resected for stage IIA and 21 nodes for stage IIB; mean 22 nodes resected in each group) with no significant differences. A review of other large series, with regard to stage II survival (AJCC 6th edition) shows similar trends. The largest singleinstitution series of open esophagectomy, by Orringer and colleagues,12 in more than 2000 patients describing an open transhiatal approach shows virtually overlapping survival curves for stage IIA and IIB disease in 481 patients with stage II esophageal cancer. The estimated 5-year overall survival in stage IIA patients was 27.8% and in those with stage IIB disease was 29.5%. A previous series from Orringer and colleagues13 comprising more than 1000 patients after transhiatal esophagectomy showed similar findings, with the estimated 5-year survival of 22% in patients with stage IIA disease and 29% in patients with stage IIB esophageal cancer. Swanson and colleagues,14 using a McKeown-type, 3-incision open esophagectomy, also reported similar findings. In the Swanson and colleagues series, 67 stage IIA patients had marginally worse survival than 30 stage IIB patients, with the estimated 3-year survival for stage IIA of 41% and stage IIB of 46%. Given the accrued knowledge since the formulation of the AJCC 6th edition revision, the apparent survival equality of patients with stage IIA and stage IIB esophageal cancer seen in our series is not atypical and has been reported in other large series of open esophagectomy as detailed earlier. Therefore, appearance of “poor prognosis” of stage IIA disease relative to stage IIB disease using the old AJCC 6th edition classification is not unusual at all. With regard to the lack of differences between the subgroups of stage II, there are several issues that merit further discussion regarding subgroup classification using the AJCC 6th edition staging system. In the AJCC 6th edition staging system, stage IIA included both T2 and T3 node-negative carcinomas, with no differences between the histologies. e46 | www.annalsofsurgery.com
The recent modification of the staging system, in AJCC 7th edition, recognized many limitations of the previous version, with significant changes to the staging system including separate classifications based on histology (adenocarcinoma vs squamous cell carcinoma) and revised criteria for stratification of subgroups. The survival in esophageal adenocarcinoma patients with T3 tumors is decreased even in node-negative patients when compared with node-negative patients with T2 tumors.15 Notably, in our series, a majority of patients who were classified as stage IIA were T3N0, and this may further explain the finding of similar survival in the stage IIA cohort. The AJCC 7th revision does not view stage T3N0M0 tumors with the same optimism as the 6th edition, where stage T3N0M0 tumors were classified as stage IIA. Indeed, according to the 7th revision, T3N0 adenocarcinomas are no longer classified as stage IIA but are reclassified as stage IIB. Even squamous cell tumors of grades 2 and 3 and of the upper or middle esophagus are now classified as stage IIB.10,15 One might expect patients with stage IIB disease to have worse survival, but the lack of a significant difference between these 2 subsets of stage II may again be related to the older AJCC 6 classification. Further analysis of survival outcomes using the new 7th edition staging system is needed. In addition, we and others have shown that the molecular staging of the tumor may predict better survival than that by the TNM classification (even after incorporating the AJCC 7th revision), and this is an area of active investigation to better stratify outcomes.16 The primary aim of our article evaluating the results of MIE was on perioperative outcomes and not the long-term survival results.1 In addition, the survival results presented are not cancer-specific survival results but rather the overall survival in the entire cohort. The patients who underwent esophagectomy with a minimally invasive approach included those with significant comorbidities. Nearly half of the patients in the series had a Charlson Comorbidity Index of greater than 3. These comorbidities may have accounted for noncancer deaths; however, this has not been analyzed separately and further work is required to address this in more detail. In addition, further follow-up is required to analyze the survival endpoints in more detail. Although we cannot make firm conclusions regarding survival based on this article, our early results did not show any significant difference in overall survival in the 2 subsets of stage II esophageal cancer in this cohort treated with MIE. In addition, the results of a meta-analysis comparing outcomes after esophagectomy with an open versus a minimally invasive approach show equivalent oncological results.17
Our MIE series comprising more than 1000 patients1 and the cumulative evidence from several large, open esophagectomy series discussed earlier lead us to suspect that in retrospect, it is not surprising that that the literature does not show consistent significant differences in survival between the subsets of stage II using the old AJCC 6th edition classification system. We thank Drs Wahed and Griffin for raising these important issues regarding the performance of a complex operation such as MIE and for giving us the opportunity to further elaborate on the impact of esophageal cancer staging on outcomes. We look forward to their results and also hope to present an update of our series incorporating the latest modifications in the staging system. Arjun Pennathur, MD Department of Cardiothoracic Surgery University of Pittsburgh Medical Center Pittsburgh, PA [email protected] William E. Gooding, MS Department of Biostatistics University of Pittsburgh Cancer Institute Pittsburgh, PA Katie S. Nason, MD Department of Cardiothoracic Surgery University of Pittsburgh Medical Center Pittsburgh, PA James D. Luketich, MD Department of Cardiothoracic Surgery University of Pittsburgh Pittsburgh, PA [email protected]
REFERENCES 1. Luketich JD, Pennathur A, Awais O. Outcomes after minimally invasive esophagectomy: review of over 1000 patients. Ann Surg. 2012;256:95– 103. 2. Lazzarino AI, Nagpal K, Bottle A, et al. Open versus minimally invasive esophagectomy. Trends of utilization and associated outcomes in England. Ann Surg. 2010;252:292–298. 3. Pennathur A, Gibson MJ, Jobe BA, et al. Oesophageal carcinoma. Lancet. 2013;381:400– 412. 4. Pennathur A, Luketich JD. Resection for esophageal cancer: strategies for optimal management. Ann Thorac Surg. 2008;85:S751–S756. 5. Pennathur A, Landreneau RJ, Luketich JD. Surgical aspects of the patient with high-grade dysplasia. Semin Thorac Cardiovasc Surg. 2005;17:326– 332. 6. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346:1128– 1137. 7. Dimick JB, Goodney PP, Orringer MB, et al. Specialty training and mortality after esophageal cancer resection. Ann Thorac Surg. 2005;80:282–286. 8. Dimick JB, Pronovost PJ, Heitmiller RE, et al. Intensive care unit staffing is associated with decreased length of stay, hospital cost, and
C 2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2014 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 262, Number 2, August 2015
complications after esophageal resection. Crit Care Med. 2001;29:904–905. 9. American Joint Committee on Cancer. AJCC Cancer Staging Manual. 6th ed. New York: Springer; 2002. 10. Esophagus and esophagogastric junction. In: Edge SB, American Joint Committee on Cancer, eds. AJCC Cancer Staging Manual. 7th ed. New York: Springer; 2010:103–115. 11. Rizk N, Venkatraman E, Park B, et al. The prognostic importance of the number of involved lymph nodes in esophageal cancer: implications for revisions of the American Joint Committee on Cancer staging system. J Thorac Cardiovasc Surg. 2006;132:1374–1381.
12. Orringer MB, Marshall B, Chang AC, et al. Two thousand transhiatal esophagectomies: changing trends, lessons learned. Ann Surg. 2007;246:363– 372; discussion 372–374. 13. Orringer MB, Marshall B, Iannettoni MD. Transhiatal esophagectomy: clinical experience and refinements. Ann Surg. 1999;230:392–400; discussion 400–403. 14. Swanson SJ, Batirel HF, Bueno R, et al. Transthoracic esophagectomy with radical mediastinal and abdominal lymph node dissection and cervical esophagogastrostomy for esophageal carcinoma. Ann Thorac Surg. 2001;72:1918–1924; discussion 1924–1925.
C 2014 Wolters Kluwer Health, Inc. All rights reserved.
Letter to the Editor
15. Rice TW, Rusch VW, Ishwaran H, et al. Cancer of the esophagus and esophagogastric junction: data-driven staging for the seventh edition of the American Joint Committee on Cancer/International Union Against Cancer Cancer Staging Manuals. Cancer. 2010;116:3763–3773. 16. Pennathur A, Xi L, Litle VR, et al. Gene expression profiles in esophageal adenocarcinoma predict survival after resection. J Thorac Cardiovasc Surg. 2013;145:505–512. 17. Sgourakis G, Gockel I, Radtke A, et al. Minimally invasive versus open esophagectomy: metaanalysis of outcomes. Dig Dis Sci. 2010;55:3031– 3040.
www.annalsofsurgery.com | e47
Copyright © 2014 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
