Resectable esophageal carcinoma: local control with neoadjuvant chemotherapy and radiation therapy

Management following endoscopic resection in elderly patients with early-stage upper gastrointestinal neoplasia

With the ongoing increase in the aging population in Japan, the number of elderly patients among the total population with upper gastrointestinal (GI) neoplasia has also been increasing. As elderly patients present unique age-related variations in their physical condition, the therapeutic approach for upper GI neoplasia should be differentiated between elderly and nonelderly patients. According to the existing guidelines, additional treatment is the standard therapy in patients who undergo endoscopic resection (ER) with a possible risk of lymph node metastasis (LNM) for upper GI neoplasia. However, due to the relatively low rate of LNM, applying additional treatment in all elderly patients may be excessive. Although additional treatment has the advantage of reducing cancer-specific mortality, its disadvantages include deteriorated quality of life, complications, and mortality in surgery. In patients with early gastric cancer, we propose treatment decisions be made using a risk-scoring system for LNM and upon considering the physical condition of the patient after ER with curability C-2. In those with superficial esophageal squamous cell carcinoma with a possible risk of LNM after ER, selective chemoradiotherapy may be a less-invasive treatment option, although the present standard treatment is esophagectomy. When considering the treatment decision, achieving a "cure" of the tumor has been regarded as critical. However, as the main cause of mortality in elderly patients with ER for upper GI neoplasia is noncancer-related death, both achieving a "cure" and also a good level of "care" is important in the management of elderly patients.

Independent risk factors that predict bile leakage after hepatectomy for hepatocellular carcinoma: Cohort study

BACKGROUND

Bile leakage is a major cause of morbidity after hepatectomy. This study aimed to identify the predictive factors for bile leakage after hepatectomy.

MATERIALS AND METHODS

Between January 2011 and December 2016, 556 patients underwent a liver resection for hepatocellular carcinoma with curative intent, and were enrolled to participate in this study. The incidence of postoperative bile leakage (POBL) was determined and the predictive factors for POBL were identified using univariate and multivariate analysis.

RESULTS

POBLs occurred in 28 patients (5.0%). The multivariate analysis identified a history of stereotactic body radiotherapy, a body mass index <20 kg/m², Child-Pugh class B cirrhosis, a central hepatectomy, and an operation time ≥375 min as risk factors that were associated with POBL. When the study cohort was grouped according to the number of the predictive factors present, the incidence of POBL increased as the number of the extant independent predictive factors increased. The POBL rate was 45.0% in patients with ≥3 predictive factors.

CONCLUSION

We determined that POBL was associated with operative mortality and identified five independent predictive factors associated with POBL. Risk stratification using these predictive factors may be useful for identifying patients at a high risk of POBL.

Role of barium esophagography in patients with locally advanced esophageal cancer: evaluation of response to neoadjuvant chemoradiotherapy

Purpose. This retrospective study examined the usefulness of barium esophagography, focusing on the luminal stenosis, in the response evaluation of neoadjuvant chemoradiotherapy (NACRT) in patients with esophageal cancer. Materials and Methods. Thirty-four patients with primary advanced esophageal cancer (≥T2) who were treated with NACRT before surgical resection were analyzed. All patients underwent barium esophagography before and after NACRT. The tumor length, volume, and percent esophageal stenosis (PES) before and after NACRT were measured. These values and their changes were compared between histopathologic responders (n = 22) and nonresponders (n = 12). Results. Posttreatment tumor length and PES in responders (4.5 cm ± 1.1 and 33.0% ± 18.5) were significantly smaller than those in nonresponders (5.8 cm ± 1.9 and 48.0% ± 12.9) (P = 0.018). Regarding posttherapeutic changes, the decrease in PES in responders (31.5% ± 13.9) was significantly greater than that in nonresponders (14.4% ± 10.7) (P < 0.001). The best decrease in PES cutoff with which to differentiate between responders and nonresponders was 18.8%, which yielded a sensitivity of 91% and a specificity of 75%. Conclusions. Decrease in PES is a good parameter to differentiate responders from nonresponders for NACRT. Barium esophagography is useful in response evaluation to NACRT in patients with locally advanced esophageal cancer.

Salvage esophagectomy after definitive chemoradiotherapy for thoracic esophageal cancer

BACKGROUND AND OBJECTIVES

Although locoregional failure frequently occurs after definitive chemoradiotherapy (CRT), the role of salvage esophagectomy has not been fully evaluated. The aim of this study was to compare the outcome of salvage esophagectomy after high-dose definitive CRT with neoadjuvant CRT.

METHODS

From 1994 to 2007, 33 patients with thoracic esophageal cancer underwent salvage esophagectomy after definitive CRT, and 115 patients underwent neoadjuvant CRT followed by surgery.

RESULTS

The postoperative mortality rate in the salvage group (12%) was higher than in the neoadjuvant group (3.6%, P = 0.059). The rates of postoperative complications were significantly higher in the salvage group than in neoadjuvant group: Anastomotic leakage (39% vs. 22%, respectively, P = 0.049), bleeding (15% vs. 1.7%, respectively, P = 0.002), cardiovascular complications (24% vs. 5.4%, respectively, P = 0.001). Univariate analysis showed that pretherapy T stage, pretherapy lymph node status, pathological T stage, and operative curability were significant prognostic factors affecting survival of patients who underwent salvage esophagectomy. In particular, patients with cT3-T4 tumors or cN1 tumors before definitive CRT showed worse prognosis after salvage esophagectomy.

CONCLUSIONS

Salvage esophagectomy after high-dose definitive CRT was associated with higher postoperative mortality and morbidity rates compared with neoadjuvant CRT. Only selected patients can be rescued by salvage esophagectomy.

Salvage esophagectomy after high-dose chemoradiotherapy for esophageal squamous cell carcinoma

OBJECTIVE

Chemoradiotherapy is a popular definitive therapy for esophageal carcinoma among many patients and oncologists. Although the complete response rates are high and short-term survival is favorable after chemoradiotherapy, persistent or recurrent locoregional disease is frequent. Salvage surgery is the sole curative intent treatment option for this course of the disease. The present study evaluates the safety and value of salvage esophagectomy for locoregional failure after high-dose definitive chemoradiotherapy for esophageal squamous cell carcinoma.

METHODS

We reviewed 59 consecutive patients with thoracic esophageal squamous cell carcinoma who underwent salvage esophagectomy after definitive chemoradiotherapy. All patients received more than 60 Gy of radiation plus concurrent chemotherapy for curative intent. The data were compared with those of patients who received esophagectomy without preoperative therapy.

RESULTS

Postoperative morbidity and mortality rates were increased among patients who underwent salvage esophagectomy compared with those who underwent esophagectomy without preoperative therapy (mean hospital stay, 38 vs 33 days; anastomotic leak rates, 31% vs 25%; respiratory complication rates, 31% vs 20%; reintubation within 1 week, 2% vs 2%; hospital mortality rates, 8% vs 2%). Tracheobronchial necrosis and gastric conduit necrosis were highly lethal complications after salvage esophagectomy; 3-year postoperative survivals were 38% and 58%, respectively.

CONCLUSION

Patients who underwent salvage esophagectomy after definitive high-dose chemoradiotherapy had increased morbidity and mortality. Nevertheless, this is acceptable in view of the potential long-term survival after salvage esophagectomy. Such treatment should be considered for carefully selected patients at specialized centers.

Comparison of barium swallow, CT and thallium-201 SPECT in evaluating responses of patients with esophageal squamous cell carcinoma to preoperative chemoradiotherapy

The aims of this study were to compare the results of thallium-201 (Tl-201) SPECT, barium swallow and CT in the assessment of the effect of preoperative chemoradiotherapy. This study consisted of 28 patients with advanced esophageal squamous cell carcinoma (AESCC) who underwent the three imaging modalities before and after preoperative chemoradiotherapy. The results were quantified using the bidimensional method for barium swallow and contrast-enhanced CT and the tumor-to-lung ratio for SPECT. The percent decrease in these quantitative values after therapy was defined as %Dba, %Dct and %Dtl respectively. The histological effect of the chemoradiotherapy was determined from the resected surgical specimen of the esophagus: grade 0, 100% viable tumor cells; grade 1a, 99-67%; grade 1b, 66-34%; grade 2, 33-1%; grade 3, no viable cells. A statistically significant difference of %Dtl between the subgroups of each grade was evident (p = 0.0433), whereas no significant differences were evident for %Dba (p = 0.1778) or %Dct (p = 0.7377). However, the overlap of %Dtl between these groups was marked. Although thallium-201 SPECT cannot be used to evaluate the therapeutic effect with acceptable accuracy, SPECT may be of additional value to barium swallow and CT in assessing the response of AESCC to preoperative chemoradiotherapy.

Treatment of thoracic esophageal carcinoma invading adjacent structures

T4 esophageal cancer is defined as the tumor invading adjacent structures, using tumor-node-metastasis (TNM) staging. For clinically T4 thoracic esophageal carcinoma, multimodality therapy, that is, neoadjuvant chemoradiotherapy (CRT) followed by surgery or definitive CRT, has generally been performed. However, the prognosis of patients with these tumors remains poor. Another strategy is needed to achieve curative treatment. In the present article, the treatment strategies employed to date are reviewed. Furthermore, the strategies for these malignancies are reassessed, based on our experiences. R1/2 and R0 resections are regarded as those with residual and no tumor after surgery. The present data show that patients who underwent R1/2 resection after neoadjuvant CRT experienced little survival benefit, while complete response (CR) cases after definitive CRT had comparatively better results. Therefore, curative surgery should not be attempted without down-staging, and definitive CRT should be the initial treatment. Then surgery is indicated for the eradication of residual cancer cells. Close surveillance is essential for early detection of relapse even after CR, because the operation will gradually become increasingly difficult due to post-CRT fibrosis. In conclusion, multimodality therapy consists of definitive CRT followed by R0 resection, which can be the treatment of choice for T4 esophageal carcinoma. These challenging treatments have the potential to constitute the most effective therapeutic strategy.

Adenocarcinoma of the esophagus and cardia: a review of the disease and its treatment

BACKGROUND

Over the past 50 years there has been a remarkable change in the epidemiology of esophageal cancer. Previously rare, adenocarcinoma of the esophagus and gastroesophageal junction is now the most common esophageal cancer, and in the United States the incidence is increasing faster than that of any other malignancy. Surveillance in patients with Barrett's esophagus is identifying adenocarcinoma at an earlier, more curable stage in many patients, and at the same time new endoscopic and surgical options are available for the therapy of these localized tumors.

METHODS

This article is a review of the epidemiology, diagnosis, staging, and treatment options for esophageal and gastroesophageal junction adenocarcinoma.

RESULTS

The epidemiology, prognosis, patterns of lymphatic metastasis, and survival for esophageal and gastroesophageal junction adenocarcinoma suggest that these tumors are similar. New options for therapy, as well as the results of surgical resection with and without chemoradiotherapy, are reviewed.

CONCLUSIONS

Surveillance programs for Barrett's are identifying patients with early, curable adenocarcinoma of the esophagus or gastroesophageal junction. Therapy for more advanced tumors hinges on local control of the disease and the eradication of systemic metastases.

Impact of induction concurrent chemoradiotherapy on pulmonary function and postoperative acute respiratory complications in esophageal cancer

STUDY OBJECTIVE

To evaluate the effects of induction concurrent chemoradiotherapy (cCRT) on pulmonary function and postoperative acute respiratory complications (PARCs).

DESIGN

A retrospective review of our patients treated with induction cCRT to determine the impact on pulmonary function and identify predictors of PARCs. Correlations were sought between patient demographics, clinical characteristics, pre-cCRT and post-cCRT pulmonary function, radiotherapy dose, chemotherapy agents, and the development of PARCs.

PARTICIPANTS

One hundred fifty-five patients treated in three separate clinical trials were identified; 47 patients received 30 Gy (150 cGy bid) of radiation concurrently with a single course of cisplatin/5-fluorouracil (5FU), and 108 patients received 45 Gy (150 cGy bid in a split course) concurrent with two courses of either cisplatin/5FU (n = 69) or cisplatin/paclitaxel (n = 39). Esophagectomy was performed in 141 of these 155 patients following cCRT.

RESULTS

cCRT was only associated with significant worsening of the diffusion capacity of the lung for carbon monoxide (Dlco), which decreased a median of 21.7% in the 45-Gy group (p = 0.007), and 8.6% in the 30-Gy group (p = 0.07). This Dlco decrease was statistically greater in the 45-Gy group than in the 30-Gy group (p = 0.02). PARCs developed in 18 patients. Percentage of predicted FEV(1) and FVC, both before and after cCRT, were both significantly higher in patients without PARCs than in patients with PARCs (p = 0.031 and p = 0.010, respectively). Post-cCRT Dlco was also significantly worse in patients with PARCs (p = 0.002). PARCs occurred significantly more often among those treated with 45 Gy (17 of 102 patients) compared to those treated with 30 Gy (1 of 39 patients) [p = 0.025]. In the 18 patients with PARCs, the median survival was only 2.1 months. This was significantly less than the 16.4-month median survival in the 123 patients who did not have PARCs (p = 0.001).

CONCLUSIONS

In patients treated with induction cCRT, higher radiation doses result in increasing impairment of gas exchange. PARCs were more likely in those patients with lower lung volumes, lower post-cCRT Dlco, and in those receiving higher radiation doses. These acute respiratory complications were also associated with a significant reduction in patient survival.

Neoadjuvant chemoradiotherapy for esophageal carcinoma: a meta-analysis

BACKGROUND

The effectiveness in improving survival of neoadjuvant chemoradiotherapy (NCRT) in patients undergoing surgery for esophageal carcinoma remains unclear.

METHODS

MEDLINE, the Cochrane Database of Systematic Reviews, BIOSIS Previews, and other resources were searched from January 1966 through January 2003. Randomized trials were selected on the basis of study design (NCRT followed by surgery vs surgery alone). Of 21 potential studies identified by abstract review, 6 (29%) met the inclusion criteria.

RESULTS

Across 6 studies, a total of 374 patients underwent NCRT followed by surgery and 364 underwent surgery alone. In 5 of the 6 studies in our meta-analysis, there was a small, non-statistically significant trend toward improved survival with NCRT. Only 1 study demonstrated a statistically significant benefit to NCRT. In our summary measure for all 6 studies, we found a small, non-statistically significant trend toward improved long-term survival in the NCRT followed by surgery group (relative risk of death in the NCRT group [RR], 0.86; 95% confidence interval [CI], 0.74 to 1.01; P = .07).

CONCLUSIONS

NCRT followed by surgery is associated with a small, non-statistically significant improvement in overall survival. Whether this benefit is sufficient to warrant the considerable expense and risks associated with NCRT should be the subject of future larger randomized trials.

[Results of surgical resection of squamous cells carcinoma of the oesophagus with or without preoperative radiochemotherapy: comparative and retrospective study]

AIM OF THE STUDY

The aim of the study was to assess preoperative radio-chemotherapy for squamous cell carcinoma of the esophagus.

MATERIAL AND METHODS

This study was a retrospective comparison between radio-chemotherapy followed by surgical resection (RCPO) and surgery alone. The RCPO group included patients with tumor located in the middle or lower third of the esophagus, staged T2 or T3 tumors without distant metastases by pretherapeutic assessment. These patients were matched with patients who underwent immediate surgery, who constituted the surgical group (CHIR). Both groups were matched for gender, age, tumor localization (middle or lower third), T stage, and surgical procedure. Each group included 77 men and 9 women, 50 tumors of the middle third and 36 of the lower third of the oesophagus, and 19 tumors T2 and 67 T3 ones.

RESULTS

Morbidity of both groups was not significantly different. The mortality was 4% in the group CHIR and 12% in the group RCPO (P =0.07). The rate of radical resection (R0) was significantly higher in the RCPO group (74% vs. 51%; P =0.001). The overall 5-year survival rate was 38% after R0 surgery and 11% after R1 or R2 surgery (P <0.0001). After R0 surgery, the 5-year survival rate was 47% in the CHIR group and 32% in the RCPO group (P =0.06).

CONCLUSION

Preoperative radiochemotherapy increases the rate of radical surgical resection without significant increase in postoperative morbidity and mortality.

Use of oesophagogastroscopy to assess the response of oesophageal carcinoma to neoadjuvant therapy

BACKGROUND

Approximately 25 per cent of patients with oesophageal cancer who undergo neoadjuvant chemoradiotherapy have no evidence of tumour in the resected specimen (complete pathological response). Those who do not respond have a poor 5-year survival compared with complete responders, regardless of whether or not they undergo surgery. Selecting for surgery only those who have a response to neoadjuvant therapy has the potential to improve overall survival as well as to rationalize the management of non-responders. This study assessed the accuracy of oesophagogastroscopy in this setting.

METHODS

A prospective database of 804 patients undergoing oesophageal resection for carcinoma was reviewed. Endoscopic assessment of the response to neoadjuvant therapy in 100 consecutive patients was compared with the pathological assessment of response. The survival for each level of response was compared.

RESULTS

At endoscopy 30 patients were considered to have had a complete response. This was confirmed pathologically in 15 patients. Survival was improved in those with a pathologically confirmed complete response (3-year survival rate 62.4 (s.e. 12.9) per cent) compared with non-responders (16.3 (s.e. 6.6) per cent). Those with microscopic residual disease also had an improved 3-year survival rate (46.3 (s.e. 12.2) per cent); however, oesophagogastroscopy failed to identify this subset.

CONCLUSION

Oesophagogastroscopy may be useful in the assessment of tumour response to neoadjuvant therapy. However, owing to its poor accuracy patients should not be excluded from further therapeutic intervention on the basis of this assessment alone.

Salvage or planned esophagectomy after chemoradiation therapy for locally advanced esophageal cancer--a review

Definitive chemoradiation (without esophagectomy) and neoadjuvant chemoradiation followed by planned esophagectomy are commonly used treatments for locally advanced esophageal cancer. These two treatment strategies have similar survival outcomes, so the value of planned esophagectomy is debated. However, persistence or recurrence of local disease is not uncommon after definitive chemoradiation. Salvage esophagectomy for isolated local failures of definitive chemoradiation is an option for selected patients. In this article we review the debate over definitive chemoradiation versus neoadjuvant chemoradiation and surgery, and then restate the argument in terms of salvage versus planned esophagectomy. Although both forms of esophagectomy are done in the setting of previous chemoradiation, they are different in several ways. Salvage esophagectomy appears to be a more morbid operation than planned esophagectomy. Surgeons supportive of the salvage esophagectomy strategy face the challenge of reducing its postoperative mortality.

Survival following intensive preoperative combined modality therapy with paclitaxel, cisplatin, 5-fluorouracil, and radiation in resectable esophageal carcinoma: A phase I report

PURPOSE

To assess the benefits of aggressive chemoradiation therapy followed by surgery in resectable esophageal carcinoma.

METHOD

Twenty-nine patients with resectable carcinoma were treated with 60 Gy of radiation (2 Gy daily for 6 weeks) and concurrent chemotherapy consisting of continuous infusion of 5-fluorouracil (200-225 mg/m(2)/d), paclitaxel (25, 40, 50, or 60 mg/m(2)) weekly over 1 hour, and cisplatin (25 mg/m(2)) weekly immediately following paclitaxel throughout radiation. Patients received either 4 cycles of postoperative paclitaxel 175 mg/m(2) over 3 hours and cisplatin 75 mg/m(2) every 3 weeks or paclitaxel 175 mg/m(2) over 3 hours and cisplatin 75 mg/m(2) every 3 weeks prior to the initiation of chemoradiation. After induction therapy and restaging, esophagectomy was performed 4 to 6 weeks later.

RESULTS

Twenty-seven patients were eligible for study (26 men, 23 with adenocarcinoma). Median age was 58 years (range 30-73). The maximum tolerated dose combination was paclitaxel 50 mg/m(2) over 1 hour weekly, cisplatin 25 mg/m(2) over 1 hour weekly, 5-fluorouracil 200 mg/m(2)/d by continuous infusion throughout radiotherapy and radiation to 60 Gy. Twenty-two patients completed therapy and underwent surgical resection. Four patients had complete pathological responses and 18 had partial responses with no mortality. The commonest dose-limiting toxicity was mucositis and esophagitis (n = 7). Median follow-up of 27 patients was 150 weeks (range 7-303). At 2-year follow-up 16/27 (59%) were alive and 15/27 (56%) were free of disease. At 4-year follow-up 12/27 (44%) were alive and free of disease. Median follow-up of 22 patients undergoing esophagectomy was 205 weeks (range 26-303). At 4-year follow-up 10/22 (45%) were alive and free of disease. For the 18 patients treated at or above the maximum tolerated dose, median follow-up was 151 weeks (range 35-206) and at 3-year follow-up 9/18 (50%) were alive and free of disease.

CONCLUSION

Aggressive combined modality therapy of esophageal carcinoma was associated with excellent long-term survival in this phase I trial.

A phase I/II study of CHARTWEL with concurrent chemotherapy in locally advanced, inoperable carcinoma of the oesophagus

AIM

To evaluate the feasibility, efficacy and toxicity of concurrent chemotherapy and continuous, hyperfractionated, accelerated radiotherapy weekend less (CHARTWEL) in the treatment of locally advanced, inoperable oesophageal cancer.

METHODS

A prospective study of 19 patients with histologically confirmed, locally advanced, inoperable carcinoma of the oesophagus. CHARTWEL was prescribed from day 1 to doses of 40.5 Gy (three patients), 42 Gy (five patients), 45 Gy (four patients), 46.5 Gy (three patients) and 49.5 Gy (four patients). Cisplatin 75 mg/m2 was administered on day 1 of radiotherapy, followed by 5-fluorouracil (5-FU) 1000 mg daily for 4 days.

RESULTS

All patients completed radiotherapy, with two requiring modification of their chemotherapy dose. Acute toxicity was acceptable, with no interruptions to treatment. The median dysphagia free time was 9.6 months with 38% of patients being dysphagia free at 42 months. The median time to locoregional relapse was 13.2 months with 50% being free at 1 year and 35% at 3.5 years. There was a trend towards greater control when the higher doses (45-49.5 Gy) were compared with the lower doses (40.5-42 Gy), P = 0.07. The median survival time was 10.7 months with 1- and 2-year survival rates of 50 and 26%, respectively. Strictures developed in seven out of 18 patients (38%), but five were found on biopsy to be due to recurrent disease. There was no other long-term toxicity and no treatment-related death occurred.

CONCLUSIONS

CHARTWEL with concomitant cisplatin/5-FU chemotherapy is a feasible treatment option in these patients. It is well tolerated, achieves a high rate of local control and effectively palliates the symptoms of dysphagia, all with relatively rapid resolution of treatment-related toxicity. The results warrant continued dose escalation to 51 Gy.

Does neoadjuvant chemoradiation downstage esophageal carcinoma?

BACKGROUND

Neoadjuvant chemoradiotherapy is administered to patients with esophageal carcinoma with the belief that this will both downstage the tumor and improve survival. Endoscopic ultrasound (EUS) is currently the most accurate method of staging esophageal cancer for tumor (T) and lymph node (N) status. Because both EUS and neoadjuvant therapy for esophageal carcinoma are relatively new, there are few data examining the relationship between EUS stage and histological stage (the stage after resection) in patients receiving neoadjuvant therapy.

METHODS

To determine the effect of neoadjuvant chemoradiotherapy on T and N stage as determined by EUS, we retrospectively compared two groups of patients with esophageal cancer staged by EUS. One group (33 patients) underwent neoadjuvant therapy (Walsh protocol: 5-fluorouracil, cisplatin, and 4000 rads of external beam radiation) followed by resection. The second group (22 patients), a control group, underwent resection without neoadjuvant therapy. We then compared histological stage to determine if there was a downstaging in the patients receiving neoadjuvant therapy. Survival was evaluated as well.

RESULTS

EUS accurately predicted histologic stage. In the control group EUS overestimated T stage in 3 of 22 (13%), underestimated N stage in 2 of 22 (9%), and overestimated N stage in 2 of 22 (9%) of patients. Preoperative radiochemotherapy downstaged (preoperative EUS stage versus pathologic specimen) 12 of 33 (36%) of patients whereas only 1 of 22 (5%) of patients in the control group was downstaged. Complete response (no tumor found in the surgical specimen) was observed in 5 of 33 (15%) of patients receiving radiochemotherapy. Survival was prolonged significantly in patients receiving radiochemotherapy: 20.6 months versus 9.6 months for those (stage II or III) patients not receiving radiochemotherapy (P <0.01). Operative time, operative blood loss, and length of stay were not significantly different between groups. Perioperative mortality was higher in the radiochemotherapy group (13%) compared with the no radiochemotherapy group (5%) but did not achieve statistical significance.

CONCLUSIONS

EUS accurately stages esophageal carcinoma. Neoadjuvant radiochemotherapy downstages esophageal carcinoma for T and N status. In our nonrandomized study, neoadjuvant therapy conferred a significant survival advantage. Operative risk appears to be increased in patients receiving neoadjuvant radiochemotherapy prior to esophagectomy.

Perioperative radiotherapy for cancer of the esophagus

Carcinomas of the esophagus represent on average about 1% to 2% of all malignant tumors. The incidence shows extreme regional differences, reflecting the established environmental and acquired risk factors for cancer of the esophagus. There has been a major shift in tumor location and histology over the last decades, with the lower third/gastroesophageal junction becoming the most common location and adenocarcinoma the most common histology in white males. There has been a striking improvement in surgical resection rates and operative mortality; however, the curative potential of surgery is likely to be highest in early-stage disease. The poor prognosis for locally advanced tumors motivated the search for multimodal approaches to improve results. While neither perioperative radiotherapy nor perioperative chemotherapy alone have significantly improved survival rates, combined radiochemotherapy, used as neoadjuvant or definitive therapy, appears more promising. For patients with advanced tumors or extensive nodal involvement, first principles and extrapolation from other tumors of the gastrointestinal tract suggest that a combination of chemotherapy and radiation is likely to be of benefit, as compared to surgery alone. As this treatment is difficult to tolerate in the postoperative setting, neoadjuvant approaches have been emphasized. Although there are promising data, and preoperative chemoradiation is widely utilized, we do not consider the benefit of this approach to have been proven unequivocally. Future progress in the treatment of esophageal cancer may require that systemic therapy be improved to the point where occult metastatic disease can be controlled, enabling the local control provided by surgery and radiation to lead to improved survival.

Influence of simultaneous neoadjuvant radiotherapy and chemotherapy on bronchoscopic findings and lung function in patients with locally advanced proximal esophageal cancer

To assess the bronchoscopic and lung function changes induced by preoperative radiochemotherapy (30 Gy radiation and 5-fluorouracil) in patients with proximal esophageal cancer, we prospectively compared the findings in 77 consecutive patients before and after the therapy. All patients completed the radiochemotherapy protocol; toxicity was minimal. Sixty-four patients underwent surgery, 48 had total gross removal of disease, and six had a complete histologic response. Of the 13 patients who developed apparent direct macroscopic signs of tumor invasion into the airways during therapy, histologic proof of cancer was obtained in only one of the abnormalities. Bronchoscopy was falsely negative in six patients in whom airway invasion of the cancer was found at surgery. Neoadjuvant therapy led to no systematic changes in the appearance of the uninvolved tracheal mucosa; microscopically, an increase in postinflammatory changes, hyperplasia, and metaplasia was found. There was no significant change in the values of lung function parameters after the therapy. No patient developed symptoms suggestive of radiation-induced lung changes, although in one of them, subtle radiologic features consistent with radiation pneumonitis were found. No patient died of postoperative pulmonary complications. The interpretation of bronchoscopy in the assessment of airway invasion of esophageal cancer after radiochemotherapy is more difficult than at baseline staging; the positive predictive value of macroscopic abnormalities without microscopic proof of cancer is low, and even with extensive sampling for histology and cytology, the procedure was falsely negative in 9.4%. Neoadjuvant therapy did not induce radiation pneumonitis or changes in lung function that could be of concern at the following operation.