NEW YORKA retrospective review of 10 years of data on patients who underwent surgical resection for esophageal cancer has shown no survival advantage for patients who had a complete pathologic response to neoadjuvant chemoradiation followed by surgery vs those who had surgery alone. In light of this finding, the researchers suggest that other therapeutic avenues be explored for patients with locally advanced esophageal cancer.
Carl R. Schmidt, MD, a research fellow in surgical oncology, Department of
Surgery, Vanderbilt University Medical Center (VUMC), reported the results on
behalf of colleagues from VUMC, Vanderbilt-Ingram Cancer Center, and Nashville
Veteran’s Administration Hospital, at the Society of Surgical Oncology 57th
Annual Cancer Symposium
The investigators undertook this study, Dr. Schmidt said, because trials and meta-analyses in the medical literature show conflicting data on both survival benefit and perioperative morbidity and mortality from preoperative neoad-juvant chemoradiation vs surgical resection alone in patients with esophageal cancer.
Included in the study were 147 patients with stages I to III esophageal cancer who underwent esophagectomy with curative intent between 1992 and 2002. Of these 147 patients, 119 had both neo-adjuvant chemoradiation therapy and surgery, and 28 were treated with surgery alone. Patients had either adenocarcinoma (n = 106) or squamous cell carcinoma (n = 41). Excluded were patients who had metastatic disease (stage IV), palliative surgery for esophageal cancer, or resection for high-grade dysplasia.
Four different regimens were used for neoadjuvant chemoradiation during the study period, as some of the patients were enrolled in phase I and II trials, Dr. Schmidt said. Clinical stage was determined by abdominal and chest CT scans; endoscopic ultrasound was performed in 64 patients (44%). A "complete response" (CR) was defined as no evidence of tumor in the resected specimen at the time of surgery, and "no CR" was defined as any gross or microscopic residual tumor in the pathologic specimen.
The median follow-up time for the patients was 21 months overall and 26 months for survivors. The investigators noted a CR in 32% of patients who underwent neoadjuvant chemoradiation, a result comparable to other reported studies. In the Tennessee study, however, no significant differences were seen in overall disease-specific survival (median, 35.9 months with CR vs 29.6 months with no CR, P = .17) or disease-free survival (median, 37.7 months with CR vs 26.5 months with no CR, P = .29) between patients who had a CR to preoperative chemoradiation vs those who did not: Kaplan-Meier survival plots for the two patient groups were similar, with actuarial curves for overall survival estimated at about 30%.
Independent prognostic factors for worse survival in patients who had neo-adjuvant therapy and surgical resection included late clinical stage, as expected, and, unexpectedly, a transthoracic vs transhiatal approach (transthoracic surgery is usually associated with improved survival). Dr. Schmidt stressed that only 20% of patients in the neoadjuvant group received transthoracic surgery, and he said a trend toward increased surgical morbidity and mortality in the transthoracic patients might explain the finding.