Esophagectomy for clinical high-grade dysplasia

Objective: Esophageal high-grade dysplasia/tumor in situ (HGD/Tis) management is in evolution. However, treatment decisions must be made on clinical staging, which may not reflect pathologic staging. Long-term randomized trial information, large treatment series, and cancer registry data do not exist to guide treatment decisions. This evaluation of esophagectomy for clinically diagnosed HGD (cHGD) serves as a reference point for future therapies. Methods: From a 1296-patient prospective esophagectomy database, 134 patients were diagnosed with cHGD (HGD without detectable mass at biopsy) before esophagectomy (mean age 60 ± 10 years, 120 [90%] male, and 132 [99%] Caucasian). Median follow-up was 7.1 years. Results: Histopathologic cell type was adenocarcinoma in 124 (93%) patients. Pathologic T (tumor) classification (pT) was 77 (57%) pHGD, 46 (34%) pT1a, eight (6%) pT1b, and one each (1%) indefinite for dysplasia, low-grade dysplasia, and pT2. Three (2%) had regional lymph node metastases (pT1N1M0). There was one hospital death (0.7%) and four deaths from recurrent cancer. Survival at 1 month, 6 months, and 5, 10, and 15 years was 99%, 97%, 96%, 94%, 82%, and 75%, respectively. Survival was at least that of a matched population. Older age and poor lung function predicted worse survival. Sixteen patients developed nonesophageal cancers, 6.1 times greater than expected. Conclusions: Despite clinical staging errors, survival following esophagectomy for cHGD is excellent. The diagnosis of cHGD does not alter survival referenced to the matched general population; however, cHGD patients appear to be at increased risk of second nonesophageal primary cancers. Therapy for cHGD should be patient specific, because patient and not cancer characteristics determine survival.