| PurposeThe esophageal cancer(EC)was one of the most common malignant tumor which accounted for a large proportion in the gastrointestinal tumors.The incidence rate of esophageal cancer in China is the highest in the world.There are two main histological types of esophageal carcinoma,squamous cell carcinoma(SCC)and adenocarcinoma(AC).The epidemiology,pathogenesis,tumor biology and survival prognosis between the two types of esophageal carcinoma are variable.About 90%of the patients in China are squamous cell carcinoma,while adenocarcinoma accounts for a smaller proportion.In contrast,the incidence rates of SCC in Western countries have declined over the past 30 years,while adenocarcinoma rates have increased.The location of squamous cell carcinomas and adenocarcinomas reflects their etiology.Adenocarcinoma is more common in the lower third of the esophagus and is derived from intestinal metaplasia following gastroesophageal reflux.Squamous cells are found throughout all the esophagus,but the upper and middle third of the esophagus are the most common sites for squamous cell carcinoma.Stage Ⅱ-Ⅲ esophageal cancer is locally advanced disease,and most patients are already in this stage when they are diagnosed.The 5-year survival rate of patients with locally advanced disease is very poor,ranging from 15%to 34%.Surgery is still the standard treatment for locally advanced esophageal cancer,but the role of radical radiotherapy and chemotherapy is becoming more and more significant.Studies have shown that squamous cell cells are more sensitive to radiation,and radical chemoradiotherapy is a optimal treatment for tumors located in the upper third of the esophagus,especially for the tumor located in the neck.However,adenocarcinoma is less sensitive to radiation,and the anatomical location of lower esophageal cancer is more suitable for surgery.The optimal treatment between surgery and radical chemoradiotherapy remains controversial in patients with stage Ⅱ-Ⅲ esophageal squamous cell carcinoma and adenocarcinoma.The purpose of this study was to evaluate the prognostic difference between surgery and radical chemoradiotherapy in patients with advanced esophageal cancer.MethodsA total of 4,235 patients with stage Ⅱ-Ⅲ esophageal cancer from 2004 to 2015 were selected from the Surveillance,Epidemiology,and End Results Database(SEER Database)for retrospective analysis.Patients were divided into two groups,squamous cell carcinoma group and adenocarcinoma group.Treatment methods were analyzed by comparing surgery and radical chemoradiotherapy.Nomograms were established to predict survival situation of patients based on a combination of several prognostic factors.Conformance index(C-index)and calibration curve(ROC Curve)were used to verify the histogram.Cox regressions were established to analyze independent prognostic factors.Kaplan Meier test(K-M curve)and Log-rank test were used to analyze and compare overall survival time(OS)and specific survival time(CSS).ResultsWe collected 1858 patients with esophageal squamous cell carcinoma accounting for 43.9%of the total,and 2377 patients with esophageal adenocarcinoma accounting for 56.1%.Univariate and multivariate analysis showed that different pathological types had different prognostic factors.Age,race,sex,pathological grade,T stage,and treatment were independent and significant prognostic factors for squamous cell carcinoma(p<0.05),but tumor location,N stage and clinical stage had no significant effect on prognosis(p>0.05).Age,pathological grade,T stage,N stage,and treatment were independent prognostic factors for adenocarcinoma(p<0.05),while race,sex,tumor location,N stage and clinical stage had no significant effects on prognosis(p>0.05).Based on all prognostic factors,nomograms can be established to further predict the 3-year and 5-year survival rates.The 3-year and 5-year Calibration curves show that the predicted probability is conform to the observed probability.In the regression analysis of patients with squamous cell carcinoma,there was no significant difference between surgery and radical chemoradiotherapy in improving prognosis(R+C vs S:HR 0.95;95%CI:0.80-1.11;p<0.05),while for adenocarcinoma patients,surgery can significantly improve the prognosis compared with radical chemoradiotherapy(R+C vs S:HR 1.19;95%CI:1.04-1.35;p<0.05).The calibration curves also showed good consistency between the predicted results and the actual observations.The K-M survival curve showed that there was no significant difference in the prognosis of patients in the squamous cell carcinoma group after surgery alone and radical chemoradiotherapy.The 3-year OS was 31.3%,26.9%and the 5-year OS was 25.2%,17.8%after surgery and radical chemoradiotherapy respectively.The 3-year CSS was 35%,32%and the 5-year CSS was 28.7%,24.3%respectively.In adenocarcinoma group,the prognosis of patients receiving surgery alone was better than that receiving radical chemoradiotherapy,the survival time was significantly prolonged.The 3-year OS was 36.1%,19.1%and the 5-year OS was 28.2%,12.9%after surgery alone and radical chemoradiotherapy respectively.The 3-year CSS was 42.7%,23.3%and the 5-year CSS was 35.3%,7.6%respectively.ConclusionFor patients with stage Ⅱ-Ⅲ esophageal cancer,many factors affecting the prognosis and the choice of treatment are also greatly different.There is no significant difference in prognosis between surgery and radical chemoradiotherapy for patients with squamous cell carcinoma.But for adenocarcinoma patients,surgery has a better prognosis than chemoradiotherapy.However,more clinical evidence is lacking.When clinical doctors making treatment recommendations,the pathological type should be considered to improve the prognosis of patients with esophageal cancer. |
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