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Ann Surg. 2018 May;267(5):826-832. doi: 10.1097/SLA.0000000000002280.

Extended Right Thoracic Approach Compared With Limited Left Thoracic Approach for Patients With Middle and Lower Esophageal Squamous Cell Carcinoma: Three-year Survival of a Prospective, Randomized, Open-label Trial.

Li B1,2, Hu H1,2, Zhang Y1,2, Zhang J1,2, Miao L1,2, Ma L1,2, Luo X1,2, Zhang Y1,2, Ye T1,2, Li H3, Zhou J4, Li Y2,5, Shen L2,5, Zhao K2,6, Fan M2,6, Zhu Z2,6, Wang J2,7, Xu J1,2, Deng Y1,2, Lu Q1,2, Jia H2,8, Cheng X1,2, Li H1,2, Zhang Y1,2, Li C9, Pan Y1,2, Liu S10, Hu H1,2, Shao L1,2, Sun Y1,2, Xiang J1,2, Chen H1,2.

Author information

1
Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.
2
Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
3
Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
4
Department of Thoracic Surgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
5
Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China.
6
Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.
7
Department of Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.
8
Center for Biomedical Statistics, Fudan University Shanghai Cancer Center, Shanghai, China.
9
Department of Lung Cancer, Tianjin Medical University Institute and Hospital, Tianjin, China.
10
Department of Thoracic Surgery, Henan Cancer Hospital, The Affiliated Cancer Hospital of Zhengzhou University, Henan, China.

Abstract

OBJECTIVE:

To investigate whether survival is improved by using the right thoracic approach (extended lymphadenectomy) compared with the left thoracic approach (limited lymphadenectomy) for esophageal cancer.

BACKGROUND:

The optimal surgical technique for esophageal cancer remains unclear.

METHODS:

Between May 2010 and July 2012, 300 patients with middle and lower thoracic esophageal carcinoma were randomized to receive esophagectomy through either the right or left thoracic approach. Of these, 286 patients with squamous cell carcinoma determined by postoperative pathology were included in this analysis. Disease-free survival (DFS) and overall survival (OS) were compared between the right (n = 146) and left thoracic groups (n = 140).

RESULTS:

The median follow-up was 55.9 months [95% confidence interval (CI): 53.1-58.6]. The 3-year DFS rates were 62% and 52% in the right and left thoracic arms, respectively [hazard ratio (HR) 0.709; 95% CI, 0.506-0.995; P = 0.047, log-rank test]. The 3-year OS rates were 74% and 60%, respectively (HR, 0.663; 95% CI, 0.457-0.961; P = 0.029). Subgroup analyses revealed longer DFS in the right thoracic arm (vs left thoracic arm) in patients with lymph node involvement (HR, 0.632; 95% CI, 0.412-0.969, P = 0.034), but not in patients without lymph node involvement (HR, 0.757; 95% CI, 0.434-1.320, P = 0.325), and in patients with R1-2 resection margins (HR, 0.495; 95% CI, 0.290-0.848, P = 0.009), but not R0 margins (HR, 0.944; 95% CI, 0.603-1.477, P = 0.801).

CONCLUSIONS:

Compared with the left thoracic approach, the right thoracic approach associated with increased DFS and OS in esophageal squamous cell carcinoma patients, particularly in those with lymph node involvement and/or R1-2 resection margins.

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