Phase II study of neoadjuvant epirubicin(E), cisplatin(C) and 5-fluorouracil(F) followed by chemoradiation with selective surgical resection/salvage for carcinomas of the esophagus and esophagogastric junction.

Abstract

84 Background: A subset of patients with local and regionally confined carcinoma of the esophagus (ES) or esophagogastric junction (EGJ) will not benefit from esophagectomy or esophagogastrectomy. Examples include medical inoperability and confined disease that is technically unresectable (T4 and/or N2-3). With that in mind we undertook to optimize the non-operative component of ES and EGJ cancer treatment, with surgery reserved for selected cases (medically fit, limited stage, suspicion of residual or recurrent disease). Methods: Eligible patients had AJCC stage T2-4,N0-3,M0 squamous or adenocarcinoma of the esophagus or esophagogastric junction. Medically inoperable patients were included if fit for ECF and chemoradiation (CRT) and regional disease could be encompassed within extended radiation fields. E (50mg/m2), C (60mg/m2) were given days 1,22 with F (200mg/m2) days 1-42 by protracted infusion. Subsequent CRT was C (100mg/m2) days 49,70 and F (200mg/m2) days 49-91 with 54 Gy in 30 fractions over 6 weeks. Complete responders by PET and biopsy received 2 additional cycles of ECF. Results: Between 2003 and 2015, 40 patients with non-metastatic squamous (n = 13) and adenocarcinoma (n = 27) signed informed consent. Most had clinical stage T3-4 (78%), positive regional lymph nodes (58%) and/or were felt to be inoperable due to medical comorbidities or advanced disease (50%). Dose reductions were allowed for grade II-III toxicity during ECF (13%) and CRT (33%). There was one treatment-related death (3%). At a median follow-up of 5 years, 10 patients (25%) have undergone esophagogastrectomy for persistent or recurrent disease. Median overall survival (OS) is 46 months. Survival at 1,3,5 and 7 years is 82%, 53%, 44% and 35% respectively. Conclusions: In local/regionally confined ES and EGJ cancer, long term survival with acceptable toxicity can be achieved with neoadjuvant ECF and CRT followed by selective surgical resection/salvage. This strategy appears to be appropriate for medically inoperable and technically unresectable cases, and can be considered for operable cases as well.