IDDF2019-ABS-0056 Minimally invasive esophagectomy after neoadjuvant chemoradiotherapy using CROSS regimen for locally advanced esophageal cancer

Abstract

Background Neoadjuvant therapy followed by surgery is the current recommended treatment for esophageal cancer. Since the publication of the landmark trial on neoadjuvant chemoradiotherapy (NACTRT), CROSS regimen has been commonly used for locally advanced esophageal cancer. However, the safety of CROSS regimen; the feasibility and short-term outcomes of minimally invasive esophagectomy (MIE) with total mediastinal lymphadenectomy after CROSS regimen has not been studied in Indian population where squamous cell carcinoma remains the predominant histological subtype and presentation with locally advanced tumor and severe malnutrition is common. Methods A retrospective analysis of a prospectively collected database of patients with histologically proven esophageal cancer and eligible for NACTRT (cT1-3, N0-1, M0). All patients underwent thoracoscopy or robot-assisted MIE with total mediastinal lymphadenectomy including dissection along the bilateral recurrent laryngeal nerve. The parameters analyzed were clinicopathological features, dropout rate with NACTRT, postoperative complications, and pathological response rate. The pathological response rate was analyzed by TRG (Tumor Regression Grading) system. Results During the study period between August 2013 and March 2018, a total of 150 patients with esophageal cancer were admitted and evaluated. Of the 150 patients, 67(44.6%) were eligible for NACTRT by CROSS protocol. Of these, 37 (55.2%) patients completed NACTRT followed by surgery. Thirty (44.7%) patients did not complete NACTRT due to complications or poor compliance. Of the patients who underwent surgery majority underwent thoracoscopic assisted MIE (n=33,89.1%) and four patients underwent Robotic-assisted MIE. Most common postoperative complication was pneumonia (n=14, 37.8%) followed by hoarseness secondary to recurrent laryngeal nerve palsy (n=12, 32.4%). Complete pathological response (TRG 1and 2) of the primary tumor was observed in 20 patients (55.5%) and 11 patients (30.5%) had a partial response (TRG 3 and 4). Of the 20 patients with the complete pathological response of the primary tumor 5 (25%) had a node-positive disease. Conclusions NACTRT followed by MIE is feasible in patients with locally advanced esophageal cancer. The nodal disease is common even in patients with the complete pathological response of the primary tumor. The dropout rate with NACTRT is high in Indian population.