Objective: The CROSS trial established the role of neoadjuvant radiation in the treatment of esophageal adenocarcinoma (EAC). While radiation response is an important factor in predicting long-term outcomes, the vast majority of patients succumb to systemic disease. The purpose of this study is to assess predictors of survival in patients with EAC following radiation therapy.
Methods: All patients who underwent resection after radiation therapy for EAC at a single institution were retrospectively identified from 2004-14. Cox-proportional hazard analyses were performed to identify clinico-pathological factors associated with survival after surgery.
Results: 322 patients underwent esophagectomy for EAC. In multivariable analysis age(P<0.0001), hospital length of stay(P=0.021), serum albumin(P=0.024), serum hemoglobin(P=0.018), and initial EUS N-stage(P=0.029) were predictive of survival. Pathologic complete (pCR) response did not correlate to improved survival(P=0.291). There was no difference in outcome based on pathologic response to radiation(pCR vs. residual disease, median survival 31.0 vs. 25.0 months, P=0.27). Pre-treatment N0 patients had better survival than N1 patients(median survival 37.2 vs. 16.3 months, P=0.002). Patients who remained N0 after radiation had much better outcomes than those that either demonstrated N1 disease in the resection specimen after radiation or were initially staged as N1(median survival, months: stayed N0 52.0, N1→N0 22.9, N0→N1 15.3, persistent N1 11.4, P<0.0001).
Conclusions: Pathologic response to radiation does not predict outcomes for patients with EAC. Patients with node positive EAC have poor outcomes even after neoadjuvant radiation therapy. These patients are at an increased risk of distant disease and should be offered additional systemic therapies.
