Oncological outcomes and recurrence patterns after robot-assisted versus video-assisted esophagectomy for cT3br/cT4b esophageal cancer.

UNLABELLED: Robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly utilized for locally advanced esophageal cancer; however, its clinical utility in challenging cases such as clinical T3 borderline resectable (cT3br) or cT4b tumors remains poorly understood. We retrospectively analyzed 60 patients with cT3br/cT4b esophageal cancer who underwent RAMIE (n=22) or video-assisted thoracoscopic esophagectomy (VATS) (n=38) after preoperative chemotherapy or chemoradiotherapy between 2014 and 2024. Three-year overall survival (OS), progression-free survival (PFS), and recurrence patterns were evaluated using a multivariable Cox proportional hazards model. A high R0 resection rate was achieved in both groups (RAMIE 90.9% vs. VATS 89.5%, p=1.000). The 3-year OS (75.4% vs. 82.7%, p=0.762) and PFS (51.8% vs. 57.8%, p=0.742) did not differ significantly between groups; however, the limited number of events precluded definitive comparative conclusions. After multivariable adjustment, the adjusted 3-year OS was 84.5% for VATS and 79.7% for RAMIE, while the adjusted 3-year PFS was 62.3% and 47.2%, respectively (both p>0.05). Adjuvant nivolumab was administered exclusively in the RAMIE group (27.3% vs. 0.0%, p<0.001). RAMIE was associated with a lower, although non-significant, rate of recurrent laryngeal nerve-area recurrence (4.5% vs. 10.5%, p=0.643) and significantly higher distant lymph node involvement (18.2% vs. 0.0%, p=0.015). One-year post-recurrence survival did not differ significantly between groups (RAMIE 80.0% vs. VATS 75.0%, p=0.941). RAMIE achieved similarly high R0 resection rates and shortterm safety compared with VATS despite a numerically higher baseline tumor burden. No significant differences in 3-year survival were observed between RAMIE and VATS, although larger multicenter studies are needed to validate these findings. BACKGROUND: Robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly utilized for locally advanced esophageal cancer. However, its clinical utility in challenging cases, such as clinical T3 borderline resectable (cT3br) or cT4b tumors, remains poorly understood. METHODS: We retrospectively analyzed 60 patients with cT3br/cT4b esophageal cancer who underwent RAMIE (n = 22) or video-assisted thoracoscopic esophagectomy (VATS) (n = 38) after preoperative chemotherapy or chemoradiotherapy between 2014 and 2024. Three-year overall survival (OS), progression-free survival (PFS), and recurrence patterns were evaluated. A multivariable Cox proportional hazards model was used to estimate adjusted hazard ratios. RESULTS: A high R0 resection rate was achieved in both groups (RAMIE 90.9% vs. VATS 89.5%, p = 1.000). The 3-year OS (75.4% vs. 82.7%, p = 0.762) and PFS (51.8% vs. 57.8%, p = 0.742) did not differ significantly between groups; however, the limited number of events precluded definitive comparative conclusions. After multivariable adjustment, the adjusted 3-year OS was 84.5% (VATS) vs. 79.7% (RAMIE), and the adjusted 3-year PFS was 62.3% vs. 47.2% (both p > 0.05). Adjuvant nivolumab was administered exclusively in the RAMIE group (27.3% vs. 0.0%, p < 0.001). RAMIE was associated with a lower, although non-significant, rate of recurrent laryngeal nerve-area recurrence (4.5% vs. 10.5%, p = 0.643) and with significantly higher distant lymph node involvement (18.2% vs. 0.0%, p = 0.015). One-year post-recurrence survival did not differ significantly (RAMIE 80.0% vs. VATS 75.0%, p = 0.941). CONCLUSIONS: RAMIE achieved similarly high R0 resection rates and short-term safety compared with VATS, despite a numerically higher baseline tumor burden. No significant differences in 3-year survival were observed between RAMIE and VATS. Larger multicenter studies are needed to validate these findings.