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Neoadjuvant Radiotherapy Facility Type Affects Anastomotic Complications After Esophagectomy

  • Original Article
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Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Esophagectomy is a complex oncologic surgery that results in lower perioperative morbidity and mortality when performed in high-volume hospitals by experienced surgeons; however, limited data exists evaluating the importance of neoadjuvant radiotherapy delivery at high- versus low-volume centers. We sought to compare postoperative toxicity among patients treated with preoperative radiotherapy delivered at an academic medical center (AMC) versus community medical centers (CMC).

Methods

Consecutive patients undergoing esophagectomy for locally advanced esophageal or gastroesophageal junction (GEJ) cancer at an academic medical center between 2008 and 2018 were reviewed. Associations between patient factors and treatment-related toxicities were calculated in univariate (UVA) and multivariable analyses (MVA).

Results

One hundred forty-seven consecutive patients were identified: 89 CMC and 58 AMC. Median follow-up was 30 months (0.33–124 months). Most patients were male (86%) with adenocarcinoma (90%) located in the distal esophagus or GEJ (95%). Median radiation dose was 50.4 Gy between groups. Radiotherapy at CMCs resulted in higher rates of re-operation after esophagectomy (18% vs 7%, p = 0.055) and increased rates of anastomotic leak (38% vs 17%, p < 0.01). On MVA, radiation at a CMC remained predictive of anastomotic leak (OR 6.13, p < 0.01).

Conclusion

Esophageal cancer patients receiving preoperative radiotherapy had higher rates of anastomotic leaks when radiotherapy was completed at a community medical center versus academic medical center. Explanations for these differences are uncertain but further exploratory analyses regarding dosimetry and radiation field size are warranted.

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Data Availability

 All data is stored separately in a data repository and will be shared upon reasonable request to the corresponding author.

References

  1. Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, Welch HG, Wennberg DE. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346(15):1128-37. doi:https://doi.org/10.1056/NEJMsa012337.

    Article  PubMed  Google Scholar 

  2. Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. JAMA. 1998;280(20):1747-51. doi:https://doi.org/10.1001/jama.280.20.1747.

    Article  CAS  PubMed  Google Scholar 

  3. Killeen SD, O'Sullivan MJ, Coffey JC, Kirwan WO, Redmond HP. Provider volume and outcomes for oncological procedures. Br J Surg. 2005;92(4):389-402. doi:https://doi.org/10.1002/bjs.4954.

    Article  CAS  PubMed  Google Scholar 

  4. Birkmeyer JD, Sun Y, Wong SL, Stukel TA. Hospital volume and late survival after cancer surgery. Ann Surg. 2007;245(5):777-83. doi:https://doi.org/10.1097/01.sla.0000252402.33814.dd.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Koëter M, van der Sangen MJ, Hurkmans CW, Luyer MD, Rutten HJ, Nieuwenhuijzen GA. Radiation dose does not influence anastomotic complications in patients with esophageal cancer treated with neoadjuvant chemoradiation and transhiatal esophagectomy. Radiat Oncol. 2015;10:59. doi:https://doi.org/10.1186/s13014-015-0361-4.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Vande Walle C, Ceelen WP, Boterberg T, Vande Putte D, Van Nieuwenhove Y, Varin O, Pattyn P. Anastomotic complications after Ivor Lewis esophagectomy in patients treated with neoadjuvant chemoradiation are related to radiation dose to the gastric fundus. Int J Radiat Oncol Biol Phys. 2012;82(3):e513-9. doi:https://doi.org/10.1016/j.ijrobp.2011.05.071.

    Article  PubMed  Google Scholar 

  7. Ingram D, Franco S. 2013 NCHS Urban-Rural Classification Scheme for Counties. Vital and health statistics Ser 1, Programs and collection procedures. 2014;2:1–73.

  8. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205-13. doi:https://doi.org/10.1097/01.sla.0000133083.54934.ae.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Slankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA. The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg. 2013;258(1):1-7. doi:https://doi.org/10.1097/SLA.0b013e318296c732.

    Article  PubMed  Google Scholar 

  10. Katayama H, Kurokawa Y, Nakamura K, Ito H, Kanemitsu Y, Masuda N, Tsubosa Y, Satoh T, Yokomizo A, Fukuda H, Sasako M. Extended Clavien-Dindo classification of surgical complications: Japan Clinical Oncology Group postoperative complications criteria. Surg Today. 2016;46(6):668-85. doi:https://doi.org/10.1007/s00595-015-1236-x.

    Article  PubMed  Google Scholar 

  11. Steyerberg EW, Neville BA, Koppert LB, Lemmens VE, Tilanus HW, Coebergh JW, Weeks JC, Earle CC. Surgical mortality in patients with esophageal cancer: development and validation of a simple risk score. J Clin Oncol. 2006;24(26):4277-84. doi:https://doi.org/10.1200/jco.2005.05.0658.

    Article  PubMed  Google Scholar 

  12. Coupland VH, Lagergren J, Lüchtenborg M, Jack RH, Allum W, Holmberg L, Hanna GB, Pearce N, Møller H. Hospital volume, proportion resected and mortality from oesophageal and gastric cancer: a population-based study in England, 2004-2008. Gut. 2013;62(7):961-6. doi:https://doi.org/10.1136/gutjnl-2012-303008.

    Article  PubMed  Google Scholar 

  13. Reavis KM, Smith BR, Hinojosa MW, Nguyen NT. Outcomes of esophagectomy at academic centers: an association between volume and outcome. Am Surg. 2008;74(10):939-43.

    Article  PubMed  Google Scholar 

  14. Merritt RE, Abdel-Rasoul M, Fitzgerald M, D'Souza DM, Kneuertz PJ. The Academic Facility Is Associated with Higher Utilization of Esophagectomy and Improved Overall Survival for Esophageal Carcinoma. J Gastrointest Surg. 2020. doi:https://doi.org/10.1007/s11605-020-04817-x.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Patel SA, Goyal S, Liu Y, Moghanaki D, Patel PR, Hanasoge S, Dhere VR, Shelton JW, Godette KD, Jani AB, Hershatter B, Fischer-Valuck BW. Analysis of Radiation Facility Volume and Survival in Men With Lymph Node-Positive Prostate Cancer Treated With Radiation and Androgen Deprivation Therapy. JAMA network open. 2020;3(12):e2025143. doi:https://doi.org/10.1001/jamanetworkopen.2020.25143.

  16. George JR, Yom SS, Wang SJ. Combined modality treatment outcomes for head and neck cancer: comparison of postoperative radiation therapy at academic vs nonacademic medical centers. JAMA otolaryngology-- head & neck surgery. 2013;139(11):1118–26. doi:https://doi.org/10.1001/jamaoto.2013.4539.

  17. Lassig AA, Joseph AM, Lindgren BR, Fernandes P, Cooper S, Schotzko C, Khariwala S, Reynolds M, Yueh B. The effect of treating institution on outcomes in head and neck cancer. Otolaryngol Head Neck Surg. 2012;147(6):1083-92. doi:https://doi.org/10.1177/0194599812457324.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Rauh LA, Saks EJ, Nakad-Rodriguez D, Showalter TN, Duska LR. Cervical cancer care in rural Virginia: The impact of distance from an academic medical center on outcomes & the role of non-specialized radiation centers. Gynecol Oncol. 2018;150(2):338-42. doi:https://doi.org/10.1016/j.ygyno.2018.06.019.

    Article  PubMed  Google Scholar 

  19. Hesse J, Chen L, Yu Y, Kang JJ, Riaz N, Tsai CJ, McBride SM, Gelblum D, Zakeri K, Lee NY. Peer Review of Head and Neck Cancer Planning Target Volumes in Radiation Oncology. Advances in radiation oncology. 2022;7(3):100917. doi:https://doi.org/10.1016/j.adro.2022.100917.

  20. Morita M, Masuda T, Okada S, Yoshinaga K, Saeki H, Tokunaga E, Endo K, Emi Y, Kakeji Y, Maehara Y. Preoperative chemoradiotherapy for esophageal cancer: factors associated with clinical response and postoperative complications. Anticancer Res. 2009;29(7):2555-62.

    PubMed  Google Scholar 

  21. Wang J, Wei C, Tucker SL, Myles B, Palmer M, Hofstetter WL, Swisher SG, Ajani JA, Cox JD, Komaki R, Liao Z, Lin SH. Predictors of postoperative complications after trimodality therapy for esophageal cancer. Int J Radiat Oncol Biol Phys. 2013;86(5):885-91. doi:https://doi.org/10.1016/j.ijrobp.2013.04.006.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Juloori A, Tucker SL, Komaki R, Liao Z, Correa AM, Swisher SG, Hofstetter WL, Lin SH. Influence of preoperative radiation field on postoperative leak rates in esophageal cancer patients after trimodality therapy. J Thorac Oncol. 2014;9(4):534-40. doi:https://doi.org/10.1097/jto.0000000000000100.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Zhang Y, Liu J, Zhang W, Deng W, Yue J. Treatment of esophageal cancer with radiation therapy -a pan-Chinese survey of radiation oncologists. Oncotarget. 2017;8(21):34946-53. doi:https://doi.org/10.18632/oncotarget.16858.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Wu AJ, Bosch WR, Chang DT, Hong TS, Jabbour SK, Kleinberg LR, Mamon HJ, Thomas CR, Jr., Goodman KA. Expert Consensus Contouring Guidelines for Intensity Modulated Radiation Therapy in Esophageal and Gastroesophageal Junction Cancer. Int J Radiat Oncol Biol Phys. 2015;92(4):911-20. doi:https://doi.org/10.1016/j.ijrobp.2015.03.030.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Han P, Hales R, Lakshminarayanan P, Cheng Z, Elledge C, Negron A, Hazell S, Hu C, Friedes C, Anderson L, Hoff J, Marrone K, Quon H, McNutt T, Voong KR. Exploring the Relationship of Radiation Dose Exposed to the Length of Esophagus and Weight Loss in Patients with Lung Cancer. Pract Radiat Oncol. 2020;10(4):255-64. doi:https://doi.org/10.1016/j.prro.2020.03.002.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Delman AM, Ammann AM, Turner KM, Vaysburg DM, Van Haren RM. A narrative review of socioeconomic disparities in the treatment of esophageal cancer. J Thorac Dis. 2021;13(6):3801-8. doi:https://doi.org/10.21037/jtd-20-3095.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Rocque GB, Williams CP, Miller HD, Azuero A, Wheeler SB, Pisu M, Hull O, Rocconi RP, Kenzik KM. Impact of Travel Time on Health Care Costs and Resource Use by Phase of Care for Older Patients With Cancer. J Clin Oncol. 2019;37(22):1935-45. doi:https://doi.org/10.1200/jco.19.00175.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Gotfrit J, Thangarasa T, Dudani S, Goodwin R, Tang PA, Monzon J, Dennis K, Cheung WY, Marginean H, Vickers M. The impact of driving time, distance, and socioeconomic factors on outcomes of patients with locally advanced rectal cancer. Public Health in Practice. 2020;1:100012. doi:https://doi.org/10.1016/j.puhip.2020.100012.

  29. Gad KT, Johansen C, Duun-Henriksen AK, Krøyer A, Olsen MH, Lassen U, Mau-Sørensen M, Oksberg Dalton S. Socioeconomic Differences in Referral to Phase I Cancer Clinical Trials: A Danish Matched Cancer Case-Control Study. J Clin Oncol. 2019;37(13):1111-9. doi:https://doi.org/10.1200/jco.18.01983.

    Article  PubMed  Google Scholar 

  30. Kamarajah SK, Lin A, Tharmaraja T, Bharwada Y, Bundred JR, Nepogodiev D, Evans RPT, Singh P, Griffiths EA. Risk factors and outcomes associated with anastomotic leaks following esophagectomy: a systematic review and meta-analysis. Dis Esophagus. 2020;33(3). doi:https://doi.org/10.1093/dote/doz089.

  31. Chen KN. Managing complications I: leaks, strictures, emptying, reflux, chylothorax. J Thorac Dis. 2014;6 Suppl 3(Suppl 3):S355–63. doi:https://doi.org/10.3978/j.issn.2072-1439.2014.03.36.

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Authors and Affiliations

  1. Department of Radiation Oncology, University of North Carolina Chapel Hill, 101 Manning Drive, Chapel Hill, NC, 27514, USA

    Ryan T. Morse

  2. Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA

    Tyler J. Mouw

  3. Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, USA

    Matthew Moreno

  4. University of Kansas School of Medicine, University of Kansas Medical Center, Kansas City, USA

    Jace T. Erwin

  5. Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, USA

    Ying Cao & Andrew Hoover

  6. Department of Surgery, University of Kansas Medical Center, Kansas City, USA

    Peter DiPasco & Mazin Al-Kasspooles

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Previous Meeting Presentation: American Society for Radiation Oncology Annual Meeting, Chicago, IL, October 24–27, 2022

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Morse, R.T., Mouw, T.J., Moreno, M. et al. Neoadjuvant Radiotherapy Facility Type Affects Anastomotic Complications After Esophagectomy. J Gastrointest Surg 27, 1313–1320 (2023). https://doi.org/10.1007/s11605-023-05660-6

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