Chemoradiotherapy followed by surgery for thoracic esophageal cancer potentially or actually involving adjacent organs

Abstract

The objective of this study was to evaluate the therapeutic usefulness of chemoradiotherapy (CRT) followed by surgery in patients with clinically T4 (cT4) esophageal cancer involving adjacent organs such as the trachea, main bronchi, and large vessels. Thirty-seven patients with cT4 squamous cell carcinoma of the thoracic esophagus were enrolled in this study. The CRT regimen comprised cisplatin (70 mg/m2) on day 1, 5-fluorouracil (700 mg/m2) on days 1-4 and external irradiation (200 cGy/day, total 30 Gy) on either days 8-26 (sequential schedule, n=15) or days 1-19 (concurrent schedule, n022). Two courses of CRT were given. The results of CRT were complete response in nine patients, partial response in 19, no change in three (minor response in two), and progressive disease in six patients. The median response duration in all responders was 172 days (range: 56-2469, n=19). After CRT, 13 patients received surgery. In 12 of these patients, tumors were completely resected. Histopathologic examination of the resected specimen revealed a discrepancy between clinical response and histopathologic effect. The median duration of survival and the 1-, 2- and 5-year survival rates were 304 days (84-3155), 45%, 35% and 23% in all patients, respectively, 866 days (190-3155), 83%, 83% and 57% in the 13 patients whose tumors were resected, and 187 days (84--2630), 25%, 5% and 5% in the 24 patients whose tumors were not resected. Grade 3 toxicity, especially hematological reactions, was noted in 13.5% (5/37) of the patients. There was one toxicity-related death (sepsis). A good outcome may be obtained with CRT, followed by surgery when feasible. However, CRT can cause toxic reactions, and close monitoring of patients is required.

Treatment of T4 Esophageal Cancer. Definitive Chemo-Radiotherapy vs Chemo-Radiotherapy Followed by Surgery

“…As shown in Tables 1 and Table 3, seven studies [10][11][12][13][14][15][16] have analyzed the outcome of patients with T4 esophageal cancer who underwent CRT-S. Basically, the combination of 5-FU (200-1000 mg/m 2 ) and CDDP (5-100 mg/m 2 ) was used in all the studies as the primary chemotherapeutic regimen. Although the doses of concurrent radiation varied across studies (36-60 Gy), all CRT in the series were performed as a "planned" treatment before surgical resection.…”

“…Furthermore, 1 (2%) patient died of treatment-related cause (pancytopenia). Ikeda et al 15) reported that during and after CRT (60 Gy/5FU + CDDP), grade 3 toxicity included anemia (14% of patients) and leukocytopenia (14% of patients). In addition, 2 patients developed esophago-bronchial fistula, 2 esophago-vascular fistula, and 1 developed esophagomediastinal fistula.…”

“…However, no combination resection was used in the other three studies (Table 3). 11,14,15) Perioperative morbidity and mortality…”

“…8) Previous studies reported the effectiveness of concurrent chemo-radiotherapy (CRT) using this regimen in advanced esophageal cancer including T4 tumors. 9) Thus, two modalities are currently in use for the treatment of esophageal tumors 10,11) ; chemo-radiotherapy followed by surgery (CRT-S) [10][11][12][13][14][15][16] and definitive chemo-radiotherapy (D-CRT). [17][18][19][20][21][22] To the best of our knowledge, there is little or no information on the differences in clinical outcome of patients with T4 esophageal tumors who undergo D-CRT and those who receive CRT-S.…”

A History of Surgery for Locally-Advanced (T4) Cancer of the Thoracic Esophagus in Japan and a Personal Perspective

“…[22][23][24][25] They reported that patients whose resected specimen showed complete response (CR) to neo-adjuvant chemoradiotherapy had the best survival. They frequently emphasized that minute residual tumors were often observed in the resected specimens, and that CR and minute residual tumors could not be defined only by pathological examinations of the resected specimen.…”