Factors affecting timing of surgery following neoadjuvant chemoradiation for esophageal cancer

Shannon J Jiang; Andrada C Diaconescu; Dyke P McEwen; Laura N McEwen; Andrew C Chang; Jules Lin; Rishindra M Reddy; William R Lynch; Sidra Bonner; Kiran H Lagisetty

doi:10.1016/j.heliyon.2023.e23212

Factors affecting timing of surgery following neoadjuvant chemoradiation for esophageal cancer

Heliyon. 2023 Dec 3;9(12):e23212. doi: 10.1016/j.heliyon.2023.e23212. eCollection 2023 Dec.

Authors

Affiliations

¹ Washington University in St. Louis, Department of Medicine, 1 Brookings Dr, St. Louis, MO, 63130, USA.
² University of Alabama at Birmingham, Department of Surgery, 1720 University Blvd, Birmingham, AL, 35294, USA.
³ University of Michigan, Department of Pharmacology, 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA.
⁴ University of Michigan, Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA.
⁵ University of Michigan, Department of Surgery, Section of Thoracic Surgery, 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA.
⁶ University of Michigan, Department of Surgery, Section of General Surgery, 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA.

Abstract

Background: Neoadjuvant chemoradiation with esophagectomy is standard management for locally advanced esophageal cancer. Studies have shown that surgical timing following chemoradiation is important for minimizing postoperative complications, however in practice timing is often variable and delayed. Although postoperative impact of surgical timing has been studied, less is known about factors associated with delays.

Materials and methods: A retrospective review was performed for 96 patients with esophageal cancer who underwent chemoradiation then esophagectomy between 2018 and 2020 at a single institution. Univariable and stepwise multivariable analyses were used to assess association between social (demographics, insurance) and clinical variables (pre-operative weight, comorbidities, prior cardiothoracic surgery, smoking history, disease staging) with time to surgery (≤8 weeks "on-time" vs. >8 weeks "delayed").

Results: Fifty-one patients underwent esophagectomy within 8 weeks of chemoradiation; 45 had a delayed operation. Univariate analysis showed the following characteristics were significantly different between on-time and delayed groups: weight loss within 3 months of surgery (3.9 ± 5.1 kg vs. 1.5 ± 3.6 kg; P = 0.009), prior cardiovascular disease (29% vs. 49%; P = 0.05), prior cardiothoracic surgery (4% vs. 22%; P = 0.01), history of ever smoked (69% vs. 87%; P = 0.04), absent nodal metastasis on pathology (57% vs. 82%; P = 0.008). Multivariate analysis demonstrated that prior cardiothoracic surgery (OR 8.924, 95%CI 1.67-47.60; P = 0.01) and absent nodal metastasis (OR 4.186, 95%CI 1.50-11.72; P = 0.006) were associated with delayed surgery.

Conclusions: Delayed esophagectomy following chemoradiotherapy is associated with prior cardiothoracic surgery and absent nodal metastasis. Further investigations should focus on understanding how these factors contribute to delays to guide treatment planning and mitigate sources of outcome disparities.

Keywords: Chemoradiation; Esophagectomy; Interval; Timing.

Grants and funding

T35 HL007690/HL/NHLBI NIH HHS/United States