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Background: Controversy exists over the optimal neoadjuvant therapy in patients with locally advanced esophageal cancer (EC). Although most groups favor neoadjuvant chemoradiation (nCRT), some prefer preoperative chemotherapy (nCT) without radiation. The objective of this study was to compare outcomes in EC patients undergoing either regimen, followed by surgery., Methods: We reviewed a prospectively collected database of EC patients undergoing esophagectomy after nCT or nCRT from 1989 to 2016. Choice of therapy was at the discretion of the multidisciplinary team. Disease-free survival (DFS) and cancer-specific survival (CSS) were compared by the Kaplan-Meier log-rank test. Independent predictors of CSS were estimated by Cox regression analysis., Results: Among 700 EC patients 338 patients were treated with nCRT (n = 112) or nCT (n = 226) followed by surgery. Patients were well matched for age, gender, and clinical stage, although patients with squamous cell carcinoma were more likely to receive nCRT (49% vs 26%, p < 0.001). At surgery 90% and 91% of nCRT and nCT patients, respectively, underwent transthoracic esophagectomy. nCRT, in comparison with nCT, was associated with similar rates of Calvien-Dindo grade III/IV complications (34% vs 33%, p = 0.423) but with a trend toward higher perioperative mortality (5% vs 1%, p = 0.064). Among adenocarcinoma patients (n = 239) the use of nCRT was associated with higher rates of complete clinical response (18% vs 7.4%), pathologically negative lymph nodes (52% vs 30%, p = 0.001), and complete pathologic response (21% vs 5.1%, p < 0.001). However, there was no difference between nCRT and nCT for 5-year DFS (28% vs 31%, p = 0.636) or CSS (51% vs 52%, p = 0.824) among adenocarcinoma patients. For patients with squamous cell carcinoma (n = 98), nCRT and nCT had similar rates of complete clinical response (31% vs 26%, p = 0.205), but the rates of negative nodes (65% vs 46%, p = 0.064) and of complete pathologic response (42% vs 12%, p < 0.05) were higher with nCRT. For these patients nCRT was associated with no statistical difference in 5-year DFS (57% vs 40%, p = 0.595) but with improved 5-year CSS (87% vs 68%, p = 0.019) compared with nCT. On multivariable analysis for CSS, nCRT predicted improved survival for patients with squamous cell carcinoma (hazard ratio, 0.242; 95% confidence interval, 0.071-0.830) but not for those with adenocarcinoma (univariate hazard ratio, 0.940; 95% confidence interval, 0.544-1.623)., Conclusions: For adenocarcinoma patients undergoing surgery for EC, nCRT leads to increased local tumor response compared with nCT alone but with no difference in survival. For squamous carcinoma patients nCRT appears to improve CSS compared with nCT. For patients with locally advanced EC targeted neoadjuvant regimens should be used depending on tumor histology., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Recent studies have suggested that lobectomy and segmentectomy hold equivalent oncologic outcomes, particularly for small, peripheral, subsolid nodules. However, for hypermetabolic nodules that are frequently associated with high rates of nodal disease, recurrence, or mortality, the optimum oncologic procedure was not assessed. We hypothesize that for hypermetabolic, cT1 N0 adenocarcinoma, lobectomy and segmentectomy are associated with comparable outcomes., Methods: A prospectively collected database was queried for patients with clinical stage IA lung adenocarcinoma who underwent lobectomy or segmentectomy (2000 to 2016) for hypermetabolic tumors (maximum standard uptake value [SUVmax] ≥ 3g/dL). To obtain balanced groups of patients, a propensity matching analysis was done., Results: A total of 414 patients had hypermetabolic tumors and underwent lobectomy or segmentectomy. Patients were propensity matched (4:1) (lobectomy: n = 156, segmentectomy: n = 46). Patients in the lobectomy group had a higher rate of pathologic nodal upstaging (17% versus 7%, p = 0.085) and a higher pathologic upstaging rate (38% versus 26%, p = 0.143) than the segmentectomy group. In addition, the lobectomy group had a higher number of resected lymph nodes than the segmentectomy group (median lymph nodes resected: 14 versus 7, p < 0.001). No differences were found in in 5-year recurrence-free survival (RFS; 72% versus 69%, p = 0.679) or in 5-year cancer-specific survival (CSS; 92% versus 83%, p = 0.557) between patients who underwent lobectomy or segmentectomy, respectively., Conclusions: Our data show that lobectomy and segmentectomy are comparable oncologic procedures for patients with carefully staged cT1 N0 lung adenocarcinoma with hypermetabolic tumors (SUVmax ≥ 3g/dL). Although lobectomy was associated with a more thorough lymph node dissection, this did not translate into a higher rate of RFS or CSS compared with segmentectomy., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Although patients with esophageal cancer (EC) often develop lymph node metastases in the cervical and recurrent laryngeal (CRL) distribution, lymphadenectomy in this field is rarely performed. The purpose of this study was to determine factors associated with CRL node positivity and to determine the appropriate indications to perform a "three field" lymphadenectomy., Methods: In a retrospective review, EC patients who underwent three-field lymphadenectomy were analyzed. Predictors of positive CRL nodes were examined univariately, then selected for inclusion in a multivariate logistic regression model., Results: From 1994 to 2009, 185 patients had a three-field lymphadenectomy, of whom 46 patients (24.9%) had positive CRL nodes. Final pathology stages (seventh edition) were I in 24 patients, II in 43, III in 109, and IV in 1 patient. Eight patients had a major pathologic response after induction therapy. On univariate analysis, variables significantly associated with positive CRL nodes included squamous cell histology, proximal location, advanced clinical presentation, the presence of clinical nodal disease, higher pT classification, and higher pN classification. There was no reduction in the rate of positive CRL nodes after induction chemotherapy. On multivariate analysis, higher pN classification (adjusted odds ratio 16.25, 95% confidence interval: 5.40 to 48.87; p < 0.0001) and squamous histology (adjusted odds ratio 6.04, 95% confidence interval: 2.21 to 16.56; p < 0.0001) predicted positive CRL nodes., Conclusions: Complete lymphadenectomy is necessary in esophageal cancer to appropriately stage patients. Low rates of positive CRL nodes are present with early clinical stage, with pT0-2 tumors, and with pN0 classification, particularly in patients with adenocarcinoma and gastroesophageal junction tumors. Dissection of the CRL field should be considered with advanced disease for adenocarcinoma and in all patients with squamous cell cancer., (Copyright © 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)