Neoadjuvant chemoradiation (NCRT) has become the preferred treatment for patients with locally advanced esophageal cancer. Survival often is correlated to degree of pathologic response; however, outcomes in patients who are found to be pathologic nonresponders (pNR) remain uninvestigated. This study was designed to evaluate survival in pNR to NCRT compared with patients treated with primary esophagectomy (PE).
Using our comprehensive esophageal cancer database, we identified patients treated with NCRT and deemed pNR along with patients who proceeded to PE. Clinical and pathologic data were compared using Fisher's exact and χ(2), whereas Kaplan-Meier estimates were used for survival analysis.
We identified 63 patients treated with NCRT and were found to have a pNR, and 81 patients who underwent PE. Disease-free (DFS) and overall survival (OS) were significantly decreased in the pNR group compared with those treated with PE (10 vs. 50 months (0-152), P < 0.001 and 13 vs. 50 months (0-152), P < 0.001, respectively). For patients with stage II disease, DFS and OS were similarly decreased in pathologic nonresponders (13 vs. 62 months (0-120), P < 0.001 and 31 vs. 62 months (0-120), P = 0.024, respectively). There were no differences in DFS or OS for patients with stage III disease (10 vs. 14 months (0-152), P = 0.29 and 10 vs. 19 months (0-152), P = 0.16, respectively).
Pathologic nonresponders to NCRT for esophageal cancer receive no benefit in DFS or OS compared with patients treated with PE. For patients with stage II disease, DFS and OS are, in fact, significantly decreased in the pNR.
"A pCR occurs in approximately 15 to 30% of cases, and approximately 60% of patients in whom pCR is achieved survive beyond five years, irrespective of the actual treatment protocol or tumor histology [4-6]. Conversely, for patients who do not respond to nCRT, the prognosis was even poorer than for patients who received primary surgery . In these cases, valuable treatment time was lost, patients unnecessarily experienced severe CRT toxicity, and may even have lost the opportunity to have potentially curative surgery. "
[Show abstract][Hide abstract] ABSTRACT: Backgrounds
In this study, we evaluated the factors associated with a pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT) for esophageal squamous cell carcinoma (ESCC).
Pre-nCRT parameters in ESCC patients treated between 1999 and 2006 were analyzed to identify predictors of pCR. All patients received 5-fluorouracil/cisplatin-based chemotherapy and external beam radiation followed by scheduled esophagectomy. Variables were analyzed using univariate and multivariate analyses with pCR as the dependent variable. Estimated pCR rate was calculated with a regression model.
Fifty-nine (20.9%) of 282 patients achieved pCR. Univariate analysis identified four patient factors (age, smoking status, drinking history and hypertension), one pre-nCRT parameter (tumor length) as significant predictors of pCR (all P <0.05). On multivariate analysis, tumor length ≤3 cm (favorable, odds ratio (OR): 4.85, P = 0.001), patient age >55 years (favorable, OR: 1.95, P = 0.035), and being a non-smoker (favorable, OR: 3.6, P = 0.003) were independent predictors of pCR. The estimated pCR rates based on a logistic regression including those three predictors were 71%, 35 to approximately 58%, 19 to approximately 38%, and 12% for patients with 3, 2, 1 and 0 predictors, respectively.
Age, smoking habit and tumor length were important pCR predictors. These factors may be used to predict outcomes for ESCC patients receiving nCRT, to develop risk-adapted treatment strategies, and to select patients who could participate in trials on new therapies.
World Journal of Surgical Oncology 05/2014; 12(1):170. DOI:10.1186/1477-7819-12-170 · 1.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Neoadjuvant chemoradiotherapy (CRT) is now considered the standard of care by many centers in the treatment of both squamous cell carcinoma (SCC) and adenocarcinoma of the esophagus. This study evaluates the effectiveness of a neoadjuvant CRT protocol, as regards pathological complete response (pCR) rate and long-term survival.
From 2003 to 2011, at Upper G.I. Surgery Division of Verona University, 155 consecutive patients with locally advanced esophageal cancers (90 SCC, 65 adenocarcinoma) were treated with a single protocol of neoadjuvant CRT (docetaxel, cisplatin, and 5-fluorouracil with 50.4 Gy of concurrent radiotherapy). Response to CRT was evaluated through percentage of pathological complete response (pCR or ypT0N0), overall (OS) and disease-related survival (DRS), and pattern of relapse.
One hundred thirty-one patients (84.5 %) underwent surgery. Radical resection (R0) was achieved in 123 patients (79.3 %), and pCR in 65 (41.9 %). Postoperative mortality was 0.7 % (one case). Five-year OS and DRS were respectively 43 and 49 % in the entire cohort, 52 and 59 % in R0 cases, and 72 and 81 % in pCR cases. Survival did not significantly differ between SCC and adenocarcinoma, except for pCR cases. Forty-nine patients suffered from relapse, which was mainly systemic in adenocarcinoma. Only three out of 26 pCR patients with previous adenocarcinoma developed relapse, always systemic.
This study suggests that patients treated with the present protocol achieve good survival and high pCR rate. Further research is necessary to evaluate whether surgery on demand is feasible in selected patients, such as pCR patients with adenocarcinoma.
[Show abstract][Hide abstract] ABSTRACT: Background:
The impact of induction chemoradiation therapy on esophageal cancer remains controversial. The purpose of this study was to evaluate the comparative effectiveness of induction chemoradiation therapy on perioperative and postoperative outcomes as well as the effect of downstaging in patients with esophageal cancer.
A retrospective study of a prospectively collected database uncovered 455 consecutive patients undergoing esophagectomies for esophageal cancer between 1999 and 2011 at a high-volume institution. Comparison cohorts were patients treated with induction chemoradiation followed by surgery (n = 180) or surgery only patients (n = 189). Median follow-up was 918 days and was complete in 97%. Propensity score analysis controlled for potential allocation-to-treatment bias and created matched groups.
Clinical stage of patients in the study was as follows: stages 0 and I, 29%; stage II, 37%; stage III, 34%. Of the 369 patients, 180 (49%) patients received induction therapy and 53 (29%) achieved pathologic complete response. Induction therapy was associated with an increased need for postoperative transfusion, higher wound infection rate, and need for longer chest tube drainage. Overall, 55% of patients undergoing induction therapy were downstaged. In clinical stage III disease, patients who were downstaged were found to have a 3- and 5-year survival benefit compared with surgery alone (3-year, 51% versus 33%, p = 0.01; and 5-year, 44% versus 33%, p = 0.04).
Induction chemoradiation therapy for esophageal cancer is associated with minimal perioperative and postoperative morbidity. Downstaging of clinical stage III patients undergoing induction therapy was associated with a 3- and 5-year survival benefit compared with clinical stage III patients undergoing surgery alone.
The Annals of thoracic surgery 04/2013; 96(1). DOI:10.1016/j.athoracsur.2013.01.074 · 3.85 Impact Factor
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