Adenocarcinoma of the esophagus: controversies and consensus.

Transition in Biology and Philosophy in the Treatment of Gastroesophageal Junction Adenocarcinoma

Most patients with esophageal cancer require multi-disciplinary management, with radiation therapy constituting a key component of therapy. In this issue, Jabbour et al. present an excellent review article on the role of radiation therapy in the postoperative management of esophageal cancer (1). The authors must be commended for this thorough, evidence-based review article. In addition to discussing postoperative radiotherapy for esophageal cancer, the authors also discuss the roles of definitive chemoradiation, preoperative chemoradiation, preoperative chemotherapy and postoperative chemotherapy. As Jabbour et al. have discussed, multiple randomized trials have evaluated whether preoperative chemoradiation improves outcomes compared to surgery alone for esophageal cancer (1). In the Cancer and Leukemia Group B (CALGB) 9781 trial, patients with T1-T3 esophageal squamous cell carcinoma or adenocarcinoma were randomized to receive either surgery alone, or surgery with preoperative chemoradiation, with a dose of 50.4 Gy in 1.8 Gy fractions, along with concurrent cisplatin and 5-fluorouracil (2). Patients in the preoperative chemoradiation arm had a median survival of 4.5 years and a 5-year survival of 39%, while patients in the surgery alone arm had a median survival of 1.8 years and a 5-year survival of 16% (P=0.002). However, it should be noted that this trial had a poor accrual of only 56 patients, out of a planned accrual of 475 patients. The case for preoperative chemoradiation has been recently bolstered by presentation of results from the CROSS trial from the Netherlands (3). In this phase III trial, 363 patients with T2-3 N0-1 esophageal carcinoma were randomized to receive either surgery alone, or surgery with preoperative chemoradiation, with a dose of 41.4 Gy in 1.8 Gy fractions, with concurrent paclitaxel (50 mg/m2) and carboplatin (AUC 2). Of the enrolled patients, 75% had adenocarcinoma, 24% had squamous cell carcinoma, and 1% had other histologies. Overall survival was significantly improved in the preoperative chemoradiation arm (P=0.01). Patients in the preoperative chemoradiation arm had a median survival of 49 months and a 3-year survival of 59%, whereas patients in the surgery alone arm had a median survival of 26 months and a 3-year survival of 48%. Formal publication of this trial is being eagerly awaited. Nevertheless, this trial has the potential of being regarded as a landmark study, which will pave the way for establishing preoperative chemoradiation as a standard of care for resectable esophageal cancer. Jabbour et al. have included a detailed discussion on the relative advantages and disadvantages of preoperative and postoperative therapy. An important advantage of preoperative chemoradiation is that smaller fields can be used in most cases. With postoperative chemoradiation, the field has to be expanded to include the anastomosis, which can potentially lead to higher rates of toxicity. While preoperative chemoradiation is likely to play an increasingly important role in the management of resectable esophageal cancer, postoperative chemoradiation will also continue to play a role. Since clinical staging is not always accurate, some patients deemed not to be candidates for preoperative chemoradiation based on clinical staging, may be found to have more advanced disease at surgery, and may then require postoperative chemoradiation. Moreover, in patients with gastroesophageal junction carcinomas, the role of post-operative chemoradiation is supported by the phase III Intergroup trial (4). In this trial, 556 patients with gastric (around 80%) or gastroesophageal junction (around 20%) adenocarcinoma were randomized to receive either surgery alone or surgery with post-operative chemoradiation. Patients in the post-operative chemoradiation arm had a median survival of 36 months and patients in the surgery alone arm had a median survival of 27 months (P=0.005). In summary, Jabbour et al. have presented a well-written, thorough, evidence-based review article on the role of postoperative chemoradiation and other approaches for the treatment of esophageal cancer. This review article will help increase our understanding of combined modality therapy for esophageal cancer.

Preoperative Chemoradiation Therapy Does Not Increase Risk of Anastomotic Leak in Patients With Gastric Cancer

Preoperative chemo(radio)therapy is increasingly used in patients with localized pancreatic adenocarcinoma, leading to pathological complete response (pCR) in a small subset of patients. However, multicenter studies with in-depth data about pCR are lacking. To investigate the incidence, outcome, and risk factors of pCR after preoperative chemo(radio)therapy. This observational, international, multicenter cohort study assessed all consecutive patients with pathology-proven localized pancreatic adenocarcinoma who underwent resection after 2 or more cycles of chemotherapy (with or without radiotherapy) in 19 centers from 8 countries (January 1, 2010, to December 31, 2018). Data collection was performed from February 1, 2020, to April 30, 2022, and analyses from January 1, 2022, to December 31, 2023. Median follow-up was 19 months. Preoperative chemotherapy (with or without radiotherapy) followed by resection. The incidence of pCR (defined as absence of vital tumor cells in the sampled pancreas specimen after resection), its association with OS from surgery, and factors associated with pCR. Factors associated with overall survival (OS) and pCR were investigated with Cox proportional hazards and logistic regression models, respectively. Overall, 1758 patients (mean [SD] age, 64 [9] years; 879 [50.0%] male) were studied. The rate of pCR was 4.8% (n = 85), and pCR was associated with OS (hazard ratio, 0.46; 95% CI, 0.26-0.83). The 1-, 3-, and 5-year OS rates were 95%, 82%, and 63% in patients with pCR vs 80%, 46%, and 30% in patients without pCR, respectively (P < .001). Factors associated with pCR included preoperative multiagent chemotherapy other than (m)FOLFIRINOX ([modified] leucovorin calcium [folinic acid], fluorouracil, irinotecan hydrochloride, and oxaliplatin) (odds ratio [OR], 0.48; 95% CI, 0.26-0.87), preoperative conventional radiotherapy (OR, 2.03; 95% CI, 1.00-4.10), preoperative stereotactic body radiotherapy (OR, 8.91; 95% CI, 4.17-19.05), radiologic response (OR, 13.00; 95% CI, 7.02-24.08), and normal(ized) serum carbohydrate antigen 19-9 after preoperative therapy (OR, 3.76; 95% CI, 1.79-7.89). This international, retrospective cohort study found that pCR occurred in 4.8% of patients with resected localized pancreatic adenocarcinoma after preoperative chemo(radio)therapy. Although pCR does not reflect cure, it is associated with improved OS, with a doubled 5-year OS of 63% compared with 30% in patients without pCR. Factors associated with pCR related to preoperative chemo(radio)therapy regimens and anatomical and biological disease response features may have implications for treatment strategies that require validation in prospective studies because they may not universally apply to all patients with pancreatic adenocarcinoma.

Editorial on combined therapy for squamous cell carcinoma of the esophagus

Background: Long-term survival in patients with esophageal cancer remains dismal despite the recent improvements in surgery, the advances in radiotherapy (RT) technology, and the refinement of systemic treatments, including the advent of targeted therapies. Although surgery constitutes the treatment of choice for early-stage disease (stage I), a multimodal approach, including preoperative or definitive chemoradiotherapy (CRT) and perioperative chemotherapy, is commonly pursued in patients with locally advanced disease. Methods: A review of the literature was performed to assess the role of RT, alone or in combination with chemotherapy, in the management of esophageal cancer. Results: Evidence from large, randomized phase III trials and meta-analyses supports the application of perioperative chemotherapy alone or preoperative concurrent CRT in patients with lower esophageal and esophagogastric junction adenocarcinomas. Preoperative CRT but not preoperative chemotherapy alone is now routinely used in patients with locally advanced squamous cell carcinoma (SCC). Additionally, definitive CRT without surgery has also emerged as a valuable approach in the management of resectable esophageal SCC to avoid surgery-related morbidity and mortality, whereas salvage surgery is reserved for those with persistent disease. Furthermore, brachytherapy offers a valuable option in the palliative treatment of patients with locally advanced, unresponsive disease. Fluorodeoxyglucose-positron emission tomography (FDG-PET) can facilitate a more accurate treatment response assessment and patient selection. Finally, the development of modern RT techniques, such as intensity-modulated and image-guided RT as well as FDG-PET-based RT planning, could further increase the therapeutic ratio of CRT. Conclusion: Altogether, CRT constitutes an important tool in the treatment armamentarium for esophageal cancer. Further optimization of CRT using modern technology and imaging, targeted therapies, and newer chemotherapeutic agents is a major challenge and should be the goal of future research and clinical trials.

Carcinoma of the esophagus is a relatively uncommon but lethal cancer that continues to kill over 90% of its victims within 5 years. Surgery is the treatment of choice for most localized esophageal cancer patients. However, despite curative resection, the 5-year survival rate ranges from 15% to 39%. The failure of surgery to cure clinically localized esophageal cancer is because of the advanced state of the disease before symptoms occur, high frequency of lymph node involvement, and the common occurrence of submucosal spread and extension to surrounding structures. Preoperative chemotherapy has been used in an attempt to decrease tumour activity, increase resectability, and improve disease-free and overall survival. A number of studies have investigated whether preoperative chemotherapy followed by surgery leads to an improvement in cure rates, but the individual reports have not been encouraging. The role of preoperative chemotherapy in the treatment of resectable thoracic esophageal cancer remains undefined. The objective of this review is to determine the role of preoperative chemotherapy on overall survival and/or quality-of-life for patients with resectable thoracic esophageal carcinoma. Trials were identified by searching the Cochrane Controlled Trials Register (Issue 2 - 2000), MEDLINE (1966 - 2000), EMBASE (1988 - 2000) and CancerLit (1993 - 2000). The references of all identified studies, review articles, and standard textbooks were examined. Members of the Cochrane UGPD Group and experts in the oncology field were contacted and asked to supply details of any outstanding clinical trials and relevant unpublished materials. There were no language restrictions. The searches were updated in June 2000. The clinical trial registers of the National Cancer Institute and the Radiation Therapy Oncology Group were consulted for ongoing trials. Types of studies Studies (published or unpublished) that randomised patients with potentially resectable carcinoma of the esophagus (of any histologic type) to chemotherapy or no chemotherapy before surgery were included in this review. Studies were excluded if they were not truly randomised (phase I or II trials), earlier versions of updated trials, if other treatment modalities (e.g. radiotherapy, hyperthermia) were used, or if there was not a surgery alone control arm. Types of participants The participants consisted of patients with potentially resectable thoracic esophageal carcinoma (of any histologic type). Trials involving patients with carcinoma of the cervical esophagus were excluded. Types of interventions Trials that compared chemotherapy before surgery (esophagectomy) with surgical resection alone (esophagectomy). Types of outcome measures The primary outcome was death at yearly intervals. Morbidity (complications), and quality-of-life were secondary outcomes. Overall mortality at yearly intervals was determined by extracting the total number of patients randomised to the treatment and control groups and the number of deaths in each group. All analyses were carried out on intention-to-treat that is patients were analyzed according to their allocated treatment, irrespective of whether they received that treatment. Mortality at 1, 2, 3, 4 and 5 years were used as endpoints of clinical relevance. If survival numbers at the specified time intervals were not given, they were estimated from the published survival curves. The number of deaths in the treatment groups (preoperative chemotherapy plus surgery) was compared to the number of deaths in the control groups (surgery alone). Treatment modalities as well as patient demographics and characteristics and side-effects were also recorded. Trials meeting the inclusion criteria were evaluated by two independent reviewers using the Jadad method A total of 14 randomised controlled trials and 1 meta-analysis of preoperative chemotherapy versus surgery alone for esophageal carcinoma were identified to be potentially eligible for review. This review is based on 7 randomised trials and 1653 patients. At 1 year the Peto odds ratio based on the fixed-effects models showed no difference in mortality between preoperative chemotherapy and surgery alone (OR = 1.03). At 2 years there was a 20% significant decrease in mortality for preoperative chemotherapy (OR = 0.80; 95% C.I. 0.65 to 0.99) but the results were not robust. The results at 3, 4, and 5 years found odds ratios tending to favour preoperative chemotherapy, but wide confidence intervals that included 1. None of the published trials reported on quality-of-life outcomes. There appeared to be an increased risk of morbidity with chemotherapy. The results of this review suggest that there is no strong evidence to recommend preoperative chemotherapy in the treatment of surgically resectable carcinomas of the thoracic esophagus. (ABSTRACT TRUNCATED)

Esophageal cancer is the sixth most common cause of death for men and, among the various gastrointestinal malignancies, it is considered to possess a relatively high malignant potential. Major causes of the difficulties in the management of this clinical entity are largely related to its clinicopathological characteristics, particularly the high frequency of complex patterns of lymph node metastasis. As a result of intense discussion beginning approximately 30 years ago, radical esophagectomy with threefield lymphadenectomy has become established in leading institutes in Asia since the mid 1980 s. Although relatively acceptable long-term outcomes have been reported, one can claim by no means that substantial evidence of survival benefit has been proved by large-scale, randomized, controlled trials (RCT). Even in the high-volume centers in Asia, further improvement of 5-year survival rates by surgery alone appears to be extremely unlikely. Therefore, optimization of multimodal treatments for localized and resectable clinical stage II/III esophageal cancer is one of the most important topics in this field. Several clinical trials in the west have demonstrated the superiority of preoperative chemoradiation therapy compared with surgery alone. However, it must be admitted that one of the most conspicuous features, and one that in the minds of many constitutes a critical limitation of the above-mentioned western studies, has been the extremely poor outcome of the surgery-alone groups. On the other hand, Japanese surgeons believe that the relatively acceptable local tumor control by transthoracic radical esophagectomy obviates the need for preoperative radiation therapy, especially because the inevitable fibrotic changes induced by radiation would negatively affect the quality of the surgical approach. Therefore, many Asian physicians treating patients with esophageal squamous cell carcinoma hesitate to apply directly the presently available results of ‘‘Western evidence’’ to ‘‘Eastern’’ esophageal cancer, in which the environment of latter is different from the former. The Japan Clinical Oncology Group (JCOG) has conducted multicenter, multimodality, prospective, clinical trials for the treatment of esophageal cancer for more than 30 years, giving full regard to these considerations. Recently, a JCOG study (JCOG9907) demonstrated significantly better overall survival after preoperative chemotherapy with two courses of cisplatin plus 5-fluorouracil followed by surgery compared with postoperative chemotherapy for resectable cStageII/III thoracic squamous cell esophageal cancer. Since publication of the results of the JCOG9907 study, preoperative chemotherapy followed by radical esophagectomy has been accepted as the standard therapeutic approach to resectable cStage II/III esophageal cancer in Japan. On the other hand, it cannot be denied that the JCOG9907 study has aroused several controversies among some extremely knowledgeable experts who are seeking to examine and interpret the present study as much scientific rigor as possible. In a recent editorial article, Ajani et al. mentioned problems that they noted in the study design of JCOG9907. As representatives of the JCOG Esophageal Cancer Study Group, we would like to respond to their specific criticisms to encourage further understanding Society of Surgical Oncology 2012

The purpose of this study was to determine differences in stage and resection rates for patients with gastric adenocarcinoma managed with upfront surgery, preoperative chemotherapy, or preoperative chemoradiation therapy . The medical records of 8382 patients with gastric or gastroesophageal cancer treated from January 1995 to November 2014 were reviewed. Chi square and logistic regression analysis was used to identify differences in treatment groups and variables associated with resection. Of 533 patients evaluated for gastrectomy, 174 patients underwent upfront surgery, 90 underwent preoperative chemotherapy, and 269 underwent preoperative chemoradiation therapy. Patients treated with preoperative therapy had more advanced endoscopic ultrasound and computed tomography imaging findings. Preoperative treatment was completed in 81% of patients administered chemotherapy and 93% of patients administered chemoradiation. Progressive, unresectable, or metastatic disease was identified in 27% of preoperative chemotherapy and 26% of chemoradiation patients. Toxicity or worsening comorbidities associated with an inability to undergo resection were identified in 2% of chemotherapy patients and 6% of chemoradiation patients. Potentially curative resection was performed in 92, 71, and 64% of patients treated with upfront surgery, preoperative chemotherapy, and preoperative chemoradiation, respectively. For patients treated with chemoradiation, the absence of regional lymphadenopathy on imaging was the only pretreatment variable associated with resection (odds ratio 1.77, 95% confidence interval 1.04-3.03; p=0.04). Patients treated with preoperative therapy often have more advanced disease prior to treatment initiation and therefore potential for disease progression. However, toxicity that prevents resection is rare, which is an important consideration in selecting preoperative treatment.

A review article may have several important purposes. Primarily it can serve as a setting where important data is collected with a goal of making it easier for physicians’ and trainees to become expert in an area and make the best treatment recommendations. However, an outstanding review article also provides new insight into the proper interpretation of the mass of available data. Esophageal cancer management is particularly in need of such a skilled overview as there are many treatment options but little data to provide real clarity about the burdens and benefits of the options under individual clinical circumstances. Jabbour and Thomas are to be congratulated for not only compiling an enormous amount of data, but doing this in a refreshing way that provides insight into the proper management of esophageal cancer (1). The stated purpose of this review article is primarily to evaluate the data that applies to radiation therapy in the postoperative management of esophageal cancer. However, the authors comprehensively review the many potential roles of radiation therapy in definitive management of locally advanced esophageal cancer, whether given definitively, preoperatively, or postoperatively. The controversy about adjuvant and neoadjuvant chemotherapy is addressed. This choice of a comprehensive review of the data contributed greatly to the value of this review article, allowing context to be placed on the data related to postoperative therapy, and in reality to provide a review more comprehensive than the goal implied by the title of the article. There are not well done definitive randomized trials to compare the outcome of postoperative therapy against preoperative therapy in esophageal cancer with modern staging and modern treatment techniques. In the United States preoperative therapy is commonly used in studies at major institutions in cooperative groups and this appears to have shaped routine clinical practice. The potential value of preoperative therapy is that adjuvant therapy could be started immediately targeting any micro metastatic deposits without allowing time for further growth, and treatment would not be given until diagnosis and staging is firmly assessed. In addition, prior to surgery it is thought that the patient’ s may be better able to tolerate aggressive chemotherapy and radiation as it can start immediately and their physical and nutritional state has not been burden by the need to recover from surgery. On the other hand when therapy is given postoperatively full staging information is available and patients who have more extensive disease discovered at the time of surgery may be spared aggressive treatments and patients with earlier stage of disease than expected may also not require such treatment. The review article has several informative and important tables that provide an overview of the management of esophageal cancer. In particular, table 1 addresses preoperative versus postoperative therapy. Information is provided about the potential pros and cons which is of significance, and yet no definitive conclusions are prevented in this review article which is appropriate given the lack of definitive data. More recently a large randomized trial published by Macdonald but including mostly gastric cancer patients and only a small proportion of patients with GE junction tumors demonstrated a substantial survival benefit to postoperative therapy (2). Data that might support specific conclusions about GE junction esophageal tumors was not provided, likely because an insufficient number of patients were in this category. Discussion as to why it is difficult to develop definitive conclusions about these different approaches may be appropriate. Certainly, the bias of treating physicians and patients related to use of these very different approaches has limited randomization. The large size of a trial that designed to properly establish differences in survival that are likely to be modest (i.e. the range of 10-15% in long term survival), is difficult to do in esophageal cancer, a relatively uncommon tumor. While it would certainly appropriate to close this article with a routine statement that definitive randomized data is needed, such information is unlikely in the near future and this review article actually provides information important to guiding therapy for patients here and now while studies are done around the world.

Combined Therapy in Esophageal Cancer.- The Value of Preoperative Radiotherapy in Esophageal Cancer: Results of a Study by the EORTC.- Preoperative (Neoadjuvant) Chemotherapy in Squamous Cell Cancer of the Esophagus.- Controlled Clinical Trial for the Treatment of Patients with Inoperable Esophageal Carcinoma: A Study of the EORTC Gastrointestinal Tract Cancer Cooperative Group.- Combination of Chemotherapy and Irradiation: A New Approach in the Treatment of Locally Advanced Esophageal Cancer.- Combined Therapy in Gastric Cancer.- Phase-III Clinical Trial of Adjuvant FAM2 (5-FU, Adriamycin and Mitomycin C) vs Control in Resectable Gastric Cancer: A Study of the EORTC Gastrointestinal Tract Cancer Cooperative Group.- The Effect of Adjuvant Chemotherapy in Gastric Carcinoma Is Dependent on Tumor Histology: 5-Year Results of a Prospective Randomized Trial.- Combined 5-Fluorouracil and Radiation Therapy Following Resection of Locally Advanced Gastric Carcinoma: A 5-Year Follow-Up.- The Value of a Multidisciplinary Approach in the Management of Gastric Cancer.- The Approach to Hepatobiliary-Pancreatic Cancer.- Approach to Primary Liver Cancer.- Biliary Duct Cancer: Therapeutic Nihilism or Prospect.- The Problem of Radical Surgery in Pancreatic Cancer and Its Implications for a Combined-Treatment Approach.- Treatment of Pancreatic Carcinoma: Therapeutic Nihilism?.- Combined Therapy in Colorectal Cancer.- Adjuvant Portal Infusion Chemotherapy in Colorectal Cancer.- Interim Analysis of a Double-Blind Phase-III Clinical Trial of Adjuvant Levamisole Versus Control in Resectable Dukes-C Colon Cancer: A Study of the EORTC Gastrointestinal Tract Cancer Cooperative Group.- The Northwest of England Rectal Cancer Trial.- Five-Year Results of a Prospective and Randomized Study: Experience with Combined Radiotherapy and Surgery of Primary Rectal Carcinoma.- The True Role of External-Beam Irradiation in the Initial Treatment of Cancer of the Rectum.- Combined-Treatment Approaches in the Management of Rectal Cancer.- Preoperative Radiotherapy and Radical Surgery as Combined Treatment in Rectal Cancer.- Combined Therapy in Anal Carcinoma.- Preoperative Radio-Chemotherapy in Anal Carcinoma.- Combined Modality Treatment of Anal Carcinoma.- Current Therapeutic Concepts in Management of Carcinoma of the Anal Canal.- Treatment of Liver Metastases of Colorectal Cancer.- Approach of the Treatment of Colorectal Liver Metastases.- Patterns of Failure Following Surgical Resection of Colorectal Cancer Liver Metastases: Rationale for a Multimodal Approach.- Regional Chemotherapy of the Liver for Colorectal Malignancies.- Interim Results of Intra-Arterial 4?-Epi-Doxorubicin for Liver Metastases.- The Use of an Implantable Vascular Occluder in the Treatment of Nonresectable Hepatic Malignancies.- Hepatic Arterial Ligation with and Without Portal Infusion in Metastatic Colorectal Cancer.- Basic Investigations on Interaction of 5-Fluorouracil and Tumor Ischemia in the Treatment of Liver Malignancies.- Current Chemotherapeutic Trials in GI-Tract Cancer.- Systemic Chemotherapy with Cisplatin, 5-Fluorouracil and Allopurinol in the Management of Advanced Epidermoid Esophageal Cancer.- Phase-II-Study with EAP (Etoposide, Adriamycin, Cis-Platinum) in Patients with Primary Inoperable Gastric Cancer and Advanced Disease.- Background for and Progress of an Ongoing EORTC Phase-II Study in Metastatic Gastric Cancer.- 5-Fluorouracil Versus a Combination of BCNU, Adriamycin, 5-FU and Mitomycin C in Advanced Gastric Cancer: A Prospective Randomized Study of the Italian Clinical Research Oncology Group.- 5-Methyltetrahydrofolic Acid (MFH4): An Effective Folate for the Treatment of Advanced Colorectal Cancer with 5-FU.- New Therapeutic Approaches to GI-Tract Cancer.- Intraoperative Radiotherapy in Carcinoma of the Stomach and Pancreas.- Is There a Role for Hyperthermia in Gastrointestinal Tract Cancer?.- Intraperitoneal Chemotherapy and Immunotherapy.- Predictive Assays for the Therapy of Rectal Carcinoma.- Therapy of Carcinoid Tumors with [131I]Meta-Iodo-Benzyl-Guanidine.- New Drug Development in Gastrointestinal-Tract Cancer.

Background: Preoperative chemoradiation therapy (CRT) or chemotherapy (CT) followed by surgery is currently being administered for advanced esophageal cancer. However, few studies have directly compared CRT and CT for treating locally advanced esophageal carcinoma. This study aimed to assess postoperative recurrence patterns and post-recurrence outcomes in patients with radical esophagectomy after CRT or triplet CT regimen with docetaxel, cisplatin, and 5-fluorouracil (DCF). Methods: This study included 325 consecutive patients with thoracic esophageal cancer who received preoperative CRT or DCF followed by curative esophagectomy between January 2010 and December 2019. We compared recurrence patterns after surgery and post-recurrence treatments between CRT and DCF. Locoregional recurrence was defined as recurrences at the primary tumor site or regional lymph nodes. Distant recurrence was defined as non-regional lymph node recurrences, systemic metastases, malignant pleural effusions, or peritoneal metastases. Results: Among 325 patients, 74 received preoperative CF + RT and 251 received preoperative DCF. A propensity score-matched cohort of 53 with CRT and 53 with DCF was included. CRT patients had tumors located in the upper esophagus and had more advanced cancer than DCF patients; however, no differences in patient characteristics were observed in the matched cohort. CRT patients had better histopathological responses and control of locoregional recurrence than DCF patients. On the other hand, distant recurrence, especially in the non-regional lymph node, lung, and pleural dissemination, significantly developed more frequently in CRT patients. Furthermore, CRT patients may have received insufficient post-recurrence treatment, owing to fewer treatment options. Therefore, although there was no difference in recurrence rate in the two groups, CRT patients had significantly poorer post-recurrence survival than DCF patients. Conclusions: Preoperative DCF could reduce distant recurrence after surgery compared to preoperative CRT. The differences in recurrence patterns can be related to the selection of post-recurrence treatment and their prognosis after recurrence.

Comparison of Preoperative Chemoradiation With Radiation or Chemotherapy Alone in Patients with Non-Metastatic, Resectable Retroperitoneal Sarcoma

Preoperative Chemoradiotherapy Prior to Esophagectomy in Elderly Patients is Not Associated With Increased Morbidity

Preoperative gemcitabine-based chemoradiation therapy for pancreatic ductal adenocarcinoma of the body and tail: Impact of splenic vessels involvement on operative outcome and pattern of recurrence