A Review of the Impact of Preoperative Chemoradiotherapy on Outcome and Postoperative Complications in Esophageal Cancer Patients

Abstract

Preoperative chemoradiotherapy has emerged in the treatment of esophageal cancer as a means to down-stage tumors, improve local control, and possibly improve overall survival. However, there are concerns that postoperative complications may be increased by preoperative chemoradiotherapy. We review the rationale for preoperative chemoradiotherapy. We review the literature to identify the potential postoperative complications, the risk of complications, and the risk factors for complications. Although individual and previous studies have shown an increased risk of postoperative complications, the 4 most recent randomized trials published after the year 2000 have not shown an increase in postoperative complications and mortality rates in patients treated with preoperative chemoradiation compared with patients treated with surgery alone. Pulmonary complications are frequently reported, and we focus on dosimetric factors that can be used to minimize lung toxicity. Several dose-volume-histogram parameters, including V10≥40%, V15≥30%, V20≥20%, have been shown to correlate with 32% to 35% of pulmonary complications including pneumonia and acute respiratory distress syndrome. More recent evidence has suggested that an absolute volume of lung spared doses of > 5 Gy (VS5) correlates with pulmonary complications. As these data show, low-dose volume may be more important in the prevention of pulmonary complications than high-dose volume. These dosimetric constraints can be used by physicians to prevent postoperative pulmonary complications in patients treated with preoperative chemoradiotherapy.

Impact of Neoadjuvant Chemoradiotherapy on Postoperative Outcomes After Esophageal Cancer Resection

“…Neoadjuvant chemoradiotherapy has been frequently correlated with increased pulmonary complications, 5,14,25 whereas the pulmonary complication rates were similar between groups in the present study. It has been suggested that the means of radiotherapy administration and radiotherapy fractionation may minimize lung toxicity and low-dose volume may be more important in the prevention of pulmonary complications than high-dose volume.…”

“…19 As reported by others and confirmed in the present large cohort study, high ASA scores, 7 supracarinal tumor location, and cervical anastomosis 9 were independent predictors of AL but not NCRT. 5,13,14,26,27 Our results suggest that NCRT does not have an impact on 90-day postoperative mortality and overall morbidity, including pulmonary complications, but does increase chylothorax rates with a trend toward more cardiovascular and thromboembolic complications. Consequently, our results suggest that NCRT does not preclude an intrathoracic anastomosis for infracarinal tumors.…”

“…Several recent studies [13][14][15]25 and reviews 5,26 have investigated the influence of NCRT on AL in EC, and conflicting data have emerged. This is so for several reasons: the studies are underpowered to study such a rare event, some were not designed to study the incidence of AL, the surgical techniques used vary widely, and in some studies groups are not comparable.…”

Stage selection for neoadjuvant radiotherapy in non‐cervical esophageal cancer: A propensity score‐matched study based on the SEER database

“…Compared with SA, neoadjuvant therapy may add to the risk of toxicity. The potential complications, which included pneumonia, acute respiratory distress syndrome, anastomotic leakage, and cardiac complications, were mainly caused by radiotherapy . In a study of Bosch et al ., a significant increase in cardiopulmonary complications was observed in the neoadjuvant therapy group.…”

“…Currently, neoadjuvant chemoradiotherapy (NCRT) has gradually gained clinical acceptance, but has the potential for degrading the staging of primary tumors, and is thus controversial, especially neoadjuvant radiotherapy (NRT) . Though NRT can reduce the size of a local tumor and make it possible to perform surgery, NRT might also increase the risk of postoperative complications, which are associated with a poor prognosis . Furthermore, the stage of non‐cervical esophageal cancer that would result in a greater benefit from NRT has not been established, and no research based on a large population has determined the correlation between NRT and prognosis in patients with esophageal cancer.…”