Treatment of esophageal cancer: surgical outcomes of 335 cases operated in a single center

ABSTRACT Objectives: the surgical approach persists as the main treatment for esophageal cancer. This study compares the patients of the same institution over time at three different times. Methods: this is a retrospective, observational, descriptive study comparing the surgical outcomes obtained by the Division of Surgical Oncology of Erasto Gaertner Hospital. The sample was divided into Period 1 (1987-1997), Period 2 (1998-2003) and Period 3 (2007-2015). Survival rates and disease-free survival were estimated by the Kaplan-Maier method. Survival predictors were identified with Cox regression. ANOVA test was used for comparison between groups. Data were analyzed with SPSS 25.0 and STATA 16, and p<0.05 was considered statistically significant. Results: a total of 335 patients underwent esophagectomy or esophagogastrectomy. When the clinical characteristics of the 3 groups were compared, there was no statistically significant difference. Neoadjuvance was significantly higher in Period 3 (55.4% of patients). We found a histological change in the diagnosis over time, with a significant increase in adenocarcinoma. Morbidity and mortality rates were higher in Period 3. The main complications were pulmonary and anastomotic fistulas. Overall survival in 5 years increased over time, reaching 59.7% in Period 3. Conclusions: better neoadjuvant treatment contributed to increase the global survival of patients, despite greater rate of immediate complications to surgery.

. It represents the sixth most common cancer among men in the country, with remarkably close incidence and mortality rates 1 . The overall five-year survival is only between 15% and 25% 2 . Worldwide, the incidence of esophageal cancer varies according to the socio-economic-cultural level of the populations studied 3 . The highest rates are found in Southern and Eastern Africa, the Middle East, and East Asia, the region being known as The Esophageal Cancer Belt, with incidences between 15 and 22 cases per 100,000 men and 6.4 to 11.7 cases per 100,000 women in population age-adjusted rates. Meanwhile, in North and South America the incidence is close to 6/100,000 men and 2.1/100,000 women 3 .
Among the gastrointestinal tract tumors, esophageal cancer has the particularity of presenting two predominant histological patterns: squamous cell carcinoma (SCC) and adenocarcinoma 4 . The esophagus is internally lined by squamous epithelium, from which the squamous cell carcinoma originates. In the distal third of the esophagus, secondary to chronic esophageal lesions, the squamous epithelium can differentiate into columnar intestinal mucosa, the tissue from which adenocarcinoma will originate 5 .
Squamous cell carcinoma represented more than 90% of cases until 20 years ago. However, the incidence of esophageal adenocarcinoma is growing and represents a considerable number of cases nowadays [5][6][7] .
The standard treatment of esophageal cancer is still discussed in the literature, but the relevance of surgery is evident 11 . In all tumors considered resectable, surgery must be strongly considered. The candidates for esophagectomy are patients with tumors that invade the muscularis mucosae (T1b -T4a) without distant metastases at the time of diagnosis (M0) 12 . The current medical literature indicates combination therapy (surgery associated with chemotherapy and radiotherapy) to increase the control of the disease compared with surgery alone 13,14 . Patients who are candidates for the procedure should be transferred to reference centers with a large annual volume of surgeries 15,16 .
The trans-thoracic esophagectomy is the standard procedure performed around the world for treating esophageal neoplastic lesions 17 . Among the most used techniques there is the Ivor Lewis esophagectomy, performed with laparotomy associated with right thoracotomy 18 . This technique provides greater visualization of the intrathoracic esophagus, allowing for better dissection and greater margins, as well as a more comprehensive lymphadenectomy.
This approach, however, is associated with greater perioperative cardiorespiratory impairment and a high risk of mediastinitis due to anastomotic fistula, which may progress to sepsis and death 17,18 . A three-incision approach (abdominal, thoracic and cervical) allows good dissection and the anastomosis at the cervical site, reducing the risk of mediastinitis 19,20 . With the evolution of radiotherapy techniques and chemotherapy drugs, the treatment of esophageal cancer has been modified over the years 17 .
This study aims to present the clinical and surgical data of patients with esophageal cancer operated in the same institution in three different historical moments, comparing the outcomes with the treatment strategies employed.