Combined therapies for squamous-cell carcinoma of the esophagus, a Southwest Oncology Group Study (SWOG-8037).

Abstract

Conservative treatment of esophageal cancer with radiation therapy has afforded few long-term survivors. In order to improve outcome, patients with locoregional disease were treated using a combined modality approach. Patients were treated with chemotherapy consisting of a 96-hour continuous infusion of 5-fluorouracil (5-FU), 1,000 mg/m2/d, days 1 to 4 and days 29 to 32; cisplatin 75 mg/m2, day 1 and 29; and radiation 3,000 rad, days 1 to 19. In the absence of progressive disease, patients underwent esophagectomy. One hundred twenty-eight patients were registered of whom 113 were eligible and 106 were evaluable. Toxicity included gastrointestinal (GI) symptoms, mucositis, and myelosuppression. One hundred two patients completed chemoradiotherapy. Following its completion, 11 patients refused surgery, six were considered poor surgical risks, and 14 had progressive disease. Of the remaining 71 patients, 16 had unresectable disease, 13 had residual disease which was incompletely resected, 24 had disease which could be completely resected, and 18 were without disease on pathologic examination. The overall operability rate was 63% and the overall resectability rate, 49%. Surgical mortality was 11%. Eighty-nine of 113 eligible patients have died, with a median survival of 12 months and a 2-year survival of 28%. The median postsurgical survival for all 71 patients was 14 months and was 32 months for those patients attaining complete remission (CR). Combined modality therapy remains an investigational approach. Attempts should be directed at increasing response rate to initial therapy. A randomized comparison between combined modality treatment and radiation therapy is necessary to definitively determine the usefulness of this more aggressive approach.

Definitive chemoradiotherapy for patients with malignant stricture due to T3 or T4 squamous cell carcinoma of the oesophagus

“…The value of chemoradiotherapy for the treatment of unresectable oesophageal carcinoma remains controversial, and only a few clinical studies have been published since the 1980s (Leichman et al, 1984;Leichman et al, 1987;Poplin et al, 1987;Coia et al, 1991;Herskovic et al, 1992;Frorastiere et al, 1993;Poplin et al, 1994). Most patients in these studies had local -regional disease (UICC stage I or II).…”

“…Several investigators have reported successful results with these modalities, either with or without surgery, against local -regional carcinoma (Leichman et al, 1984;Leichman et al, 1987;Poplin et al, 1987;Coia et al, 1991;Frorastiere et al, 1993;Poplin et al, 1994). The combination of 5-fluorouracil (5-FU) and cisplatin (CDDP) has become a standard regimen, not only because of the clinical outcome but also because of the synergism between the two agents and their radiosensitising effects (Douple et al, 1980;Scanlon et al, 1986;Byfield, 1990).…”

Chemoradiotheraphy of Esophageal Cancer

“…In our own study published in 1991, 20% received a histologically complete response, and in this group all patients were long-term survivors. In all studies so far reported, improved survival is observed for patients who are pathologically complete responders (40)(41)(42)(43)(44)(45)(46)(47). A recently reported abstract of a Medical Research Council trial of chemotherapy before surgery versus surgery alone shows a statistically signi cant improvement in survival (48).…”

“…The swallowing function is often well restituted for responding patients and for those with remaining tumors surgical salvage is still possible. Several studies with preoperative chemoradiation have shown that a pathologically complete remission is predictive of those who will be long-term survivors (40)(41)(42)(43)(44)(45)(46)(47). This also stresses the need for a surgical resection.…”

Role of radiotherapy in the pre-operative management of carcinoma of the esophagus

“…The use of pre-operative chemoradiotherapy in esophageal cancer was first used in 2 phase Ⅱ studies based in the United States [6,7] . The Southwestern Oncology Group trial accrued 113 patients treated with pre-operative chemoradiotherapy using concurrent cisplatin, fluorouracil and 30 Gy.…”