Surgical and endoscopic management of clinical T1b esophageal cancer

Objective Esophageal cancers that invade the submucosa (T1b) have increased risk for occult lymph node metastases. To avoid the morbidity and recovery from esophagectomy, patients with cT1bN0 tumors have been increasingly managed endoscopically. We hypothesized that tumor attributes could predict upstaging and outcome associated with surgical and endoscopic treatment. Our objective was to evaluate the comparative effectiveness of esophagectomy across different cT1bN0 tumor attributes. Methods Treatment-naïve patients who underwent endoscopic management or esophagectomy for a clinical stage cT1bN0 esophageal cancer diagnosed between 2010-2018 in the National Cancer Database were identified. Factors associated with upstaging were assessed by logistic regression. Adjusted survival was assessed by Kaplan Meier analysis of 528 propensity matched pairs and accelerated time failure models, stratified across tumor attributes. Results Overall, 1469 cT1bN0 patients were identified, 926 underwent esophagectomy and 543 were managed endoscopically. In general, endoscopic patients were older (median 71 IQR 63-78 vs.66 IQR 60-72, P<0.0001) with smaller tumors compared to the esophagectomy patients. Nodal upstaging was associated with lymphovascular invasion, OR= 6.88, CI (4.39-10.77) P<0.0001, poor tumor differentiation, OR=2.77, CI (1.30-5.88), P=0.0081, and tumor size >1cm, OR=3.19, CI (1.49-6.83), P=0.0028. Overall survival was better among propensity-matched esophagectomy patients (5-year 68.4% vs. 59.7% endoscopic, P<0.001). However, accelerated time failure models suggested similar outcomes among patients with well-differentiated tumors managed surgically or endoscopically. Conclusion Esophagectomy was associated with improved survival for cT1bN0 esophageal cancer, however endoscopic treatment may achieve similar survival in patients with favorable tumor attributes. Further study is warranted.