Neoadjuvant strategies in resectable carcinoma esophagus: a meta-analysis of randomized trials

Abstract

Background: The survival benefit of neoadjuvant therapy in resectable carcinoma esophagus has been elucidated. We performed a meta-analysis in light of new studies and long-term results of past trials. The search strategy was refined to include only "neoadjuvant" so that any bias by adjuvant treatment is eliminated. Methods: A detailed search of MEDLINE, Embase, and Cochrane Library was done. Only published randomized English language trials were included. Data were categorized as neoadjuvant concurrent chemoradiation (NACRT), neoadjuvant chemotherapy (NACT), neoadjuvant radiotherapy (NART), and neoadjuvant sequential chemoradiotherapy (SCRT). Meta-analysis was done using odds ratio (OR) and 95% CI using fixed/random effects model. Heterogeneity was tested by chi-square and I 2 test. Z probability calculated significant difference across subgroups. Outcomes assessed were overall survival (OS) and disease-free survival (DFS) at 3 and 5 years, respectively, mortality (30/90 day) and failures (local/systemic). Results: Twenty-five randomized trials involving 5272 patients were included for quantitative analysis. NACRT was evaluated in 12 studies (2676 patients). Superior 3-year OS (OR = 0.68 CI 0.52-0.90, p = 0.007), 3-year DFS (OR = 0.55 CI 0.45-0.68, p = 0.00001), and 5-year DFS (OR = 0.59 CI 0.47-0.74, p = 0.00001), with lower failures (OR = 0.52 CI 0.37-0.73, p = 0.0001), were seen in favor of NACRT at the cost of increased perioperative mortality (OR = 1.79 CI 1.15-2.80, p = .01). However, 5-year OS (OR = 0.78 CI 0.60-0.1.01, p = 0.06) was not found to be significantly superior. NACT, NART, and SCRT were not found to have any benefit over surgery alone. Conclusion: This meta-analysis presents strong evidence favoring NACRT over upfront surgery. It also shows no survival advantage of neoadjuvant chemotherapy.

The role of vascular invasion and lymphatic invasion in predicting recurrent thoracic oesophageal squamous cell carcinoma

“…With the release of a series of clinical study results [ 35 – 37 ], neoadjuvant therapy (neoadjuvant chemotherapy and neoadjuvant chemoradiation) is recommended by many guidelines as induction therapy for oesophageal cancer, and our clinical practice is also recommended in accordance with relevant guidelines. A meta-analysis of different neoadjuvant treatments for oesophageal cancer included 25 randomized trials involving 5272 patients, its result showed that compared with chemotherapy, neoadjuvant concurrent chemoradiation has obvious advantages in the survival of surgical treatment of resectable oesophageal cancer [ 38 ]. Our study was to explore the effect of LVI of thoracic oesophageal cancer on the prognosis of patients.…”

Patterns and timing of recurrence in esophageal squamous cell carcinoma patients treated with neoadjuvant chemoradiotherapy plus esophagectomy

“…Neoadjuvant chemotherapy (NAC) or neoadjuvant chemoradiotherapy (NACRT) are common strategies that have been shown to improve the prognosis of patients with advanced esophageal cancer [1][2][3][4][5]. Indeed, a recent meta-analysis found that NACRT followed by surgery has a survival benefit over surgery alone [6]. Moreover, several other meta-analyses suggest that, given its histopathological and/or long-term survival benefit, NACRT should be recommended over NAC to patients with esophageal cancer [7][8][9].…”

Long-term survival outcomes of esophageal cancer after minimally invasive Ivor Lewis esophagectomy

“…In contrast, a significant proportion of our patients (92%) underwent neoadjuvant concurrent chemoradiation, which may be an additional factor contributing to our favorable survival rates. In a recent meta-analysis, Kumar and colleagues report a significant survival benefit at 3-year OS ( p < 0.01 ) , 3-year DFS ( p < 0.001), and 5-year DFS ( p < 0.001) in those patients who underwent neoadjuvant concurrent chemoradiation over upfront surgery [ 34 ].…”