Abstract
BackgroundWe aimed to assess whether high-dose preoperative chemoradiotherapy (CRT) improves outcome in esophageal cancer patients compared to surgery alone and to define possible prognostic factors for overall survival.MethodsHundred-and-seven patients with disease stage IIA - III were treated with either surgery alone (n = 45) or high-dose preoperative CRT (n = 62). The data were collected retrospectively. Sixty-seven patients had adenocarcinomas, 39 squamous cell carcinomas and one undifferentiated carcinoma. CRT was given as three intensive chemotherapy courses by cisplatin 100 mg/m2 on day 1 and 5-fluorouracil 1000 mg/m2/day, from day 1 through day 5 as continuous infusion. One course was given every 21 days. The last two courses were given concurrent with high-dose radiotherapy, 2 Gy/fraction and a median dose of 66 Gy. Kaplan-Meier survival analysis with log rank test was used to obtain survival data and Cox Regression multivariate analysis was used to define prognostic factors for overall survival.ResultsToxicity grade 3 of CRT occurred in 30 (48.4%) patients and grade 4 in 24 (38.7%) patients of 62 patients. One patient died of neutropenic infection (grade 5). Fifty percent (31 patients) in the CRT group did undergo the planned surgery. Postoperative mortality rate was 9% and 10% in the surgery alone and CRT+ surgery groups, respectively (p = 1.0). Median overall survival was 11.1 and 31.4 months in the surgery alone and CRT+ surgery groups, respectively (log rank test, p = 0.042). In the surgery alone group one, 3 and 5 year survival rates were 44%, 24% and 16%, respectively and in the CRT+ surgery group they were 68%, 44% and 29%, respectively. By multivariate analysis we found that age of patient, performance status, alcoholism and > = 4 pathological positive lymph nodes in resected specimen were significantly associated with overall survival, whereas high-dose preoperative CRT was not.ConclusionWe found no significant survival advantage in esophageal cancer stage IIA-III following preoperative high-dose CRT compared to surgery alone. Patient's age, performance status, alcohol abuse and number of positive lymph nodes were prognostic factors for overall survival.
Highlights
Patients with esophageal cancer continue to have a poor prognosis with a 5 year survival rate less than 20%
All chemotherapy dose reductions were due to toxicity
By univariate analysis we found that a favorable overall survival was associated with preoperative CRT (p = 0.042, Figure 2), younger age (p = 0.017), better performance status (p < 0.001), no alcoholism (p = 0.028) and transthoracic esophagectomy (TTE) (p = 0.048)
Summary
Patients with esophageal cancer continue to have a poor prognosis with a 5 year survival rate less than 20%. Several factors contribute to this poor outcome, of which the most important is that the vast majority of patients demonstrate either locally advanced or metastatic disease at the time of diagnosis. Surgery has been relatively unsuccessful in controlling loco-regionally-advanced tumors and preoperative concomitant chemotherapy with radio-. Improved complete response and survival rates were reported with this regimen which applied cisplatin 100 mg/m2 day 1 and 5-Fluorouracil 1000 mg/m2/day, day 1-5 as continuous infusion. We applied high-dose RT concomitant with intensive chemotherapy (Wayne State Regimen) in an attempt to improve outcome. We aimed to assess whether high-dose preoperative chemoradiotherapy (CRT) improves outcome in esophageal cancer patients compared to surgery alone and to define possible prognostic factors for overall survival
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