Recurrence patterns after primary surgery and neoadjuvant chemoradiotherapy for esophageal adenocarcinoma

Our publication Across the CROSS in daily practice challenged the routine use of neoadjuvant chemoradiotherapy (nCRT) for locally advanced esophageal adenocarcinoma, showing a comparable 5-year overall survival after primary surgery. Disease-free survival, however, did show a tendency towards higher recurrence rates in the primary surgery group, although not reaching statistical significance. This current study aims to differentiate recurrence patterns and its final impact on overall survival.

This retrospective cohort study with propensity score-matched analysis included all surgically treated patients between 2000 and 2018 with locally advanced adenocarcinoma (cT_1/2N₊ or cT_3/4N_0/+). Exclusion criteria of the CROSS trial were applied. Patients were matched on age, Charlson comorbidity score, clinical tumor length, and lymph node status. Primary end point was time to recurrence.

One hundred and forty-nine propensity score-matched cases were defined in each group. Primary surgery resulted in more recurrences (73.2% vs. 57.0%, p = 0.003). However, nCRT resulted in a shorter time to overall recurrence (6.3 vs. 11.5 months, p = 0.004) and locoregional recurrence (6.3 vs. 13.6 months, p = 0.005). Additionally, overall survival after diagnosis of recurrence was significantly shorter for nCRT than for primary surgery (6.9 vs. 9.6 months, p = 0.03).

Our propensity score-matched results indicate that both overall and locoregional recurrences occur significantly earlier in nCRT patients and overall survival after recurrence is significantly shorter after nCRT. These findings might explain the comparable 5-year overall and disease-free survival of both groups.Abbreviations: CROSS: trial chemoradiotherapy for oesophageal cancer followed by surgery study; CT scan: computed tomography scan; HR: hazard ratio; nCRT: neoadjuvant chemoradiotherapy.