Abstract
BackgroundPatients with locally advanced esophageal or gastroesophageal adenocarcinoma benefit from multimodal therapy concepts including neoadjuvant chemoradiation (nCRT), respectively, perioperative chemotherapy (pCT). However, it remains unclear which treatment is superior concerning postoperative morbidity.MethodsIn this study, we compared the postsurgical survival (30-day/90-day/1-year mortality) (primary endpoint), treatment response, and surgical complications (secondary endpoints) of patients who either received nCRT (CROSS protocol) or pCT (FLOT protocol) due to esophageal/gastroesophageal adenocarcinoma. Between January 2013 and December 2017, 873 patients underwent Ivor Lewis esophagectomy in our high-volume center. 339 patients received nCRT and 97 underwent pCT. After 1:1 propensity score matching (matching criteria: sex, age, BMI, ASA score, and Charlson score), 97 patients per subgroup were included for analysis.ResultsAfter matching, tumor response (ypT/ypN) did not differ significantly between nCRT and pCT (p = 0.118, respectively, p = 0.174). Residual nodal metastasis occurred more often after pCT (p = 0.001). Postsurgical mortality was comparable within both groups. No patient died within 30 or 90 days after surgery while the 1-year survival rate was 72.2% for nCRT and 68.0% for pCT (p = 0.47). Only grade 3a complications according to Clavien–Dindo were increased after pCT (p = 0.04). There was a trend towards a higher rate of pylorospasm within the pCT group (nCRT: 23.7% versus pCT: 37.1%) (p = 0.061). Multivariate analysis identified pCT, younger age, and Charlson score as independent variables for pylorospasm.ConclusionBoth nCRT and pCT are safe and efficient within the multimodal treatment of esophageal/gastroesophageal adenocarcinoma. We did not observe differences in postoperative morbidity. However, functional aspects such as gastric emptying might be more frequent after pCT.
Highlights
Adenocarcinoma of the esophageal (EAC) and the gastroesophageal junction are still devastating diseases with only a poor prognosis
Different treatment concepts coexist: On the one hand, there is the wide-spread neoadjuvant chemoradiation (including a cumulative radiation dose of 41.4 Gy (23 fractions with 1.8 Gy) plus carboplatin/paclitaxel) which was systematically examined within the so-called CROSS trial demonstrating an improved survival among EAC patients (43 months compared to 27 months) (Van Hagen et al 2012; Shapiro et al 2015)
We excluded 437 patients from further analysis due to disseminated metastasis at the time of diagnosis (n = 17), different histopathological subtype other than adenocarcinoma (n = 208), or since they did not qualify for multimodal neoadjuvant treatment (n = 212)
Summary
Adenocarcinoma of the esophageal (EAC) and the gastroesophageal junction are still devastating diseases with only a poor prognosis. The common perioperative chemotherapy (pCT) with 5-fluorouracil (5-FU), leucovorin, oxaliplatin, and docetaxel (so-called FLOT protocol) achieved a median overall survival of 50 months in EAC patients (Al-Batran et al 2019) It remains unclear which concept (chemoradiation or chemotherapy) is superior while both treatment regimens have different adverse side effects: about 12% of patients with nCRT develop esophagitis, thrombocytopenia, neutropenia, or leucopenia (Van Hagen et al 2012). Patients with locally advanced esophageal or gastroesophageal adenocarcinoma benefit from multimodal therapy concepts including neoadjuvant chemoradiation (nCRT), respectively, perioperative chemotherapy (pCT). It remains unclear which treatment is superior concerning postoperative morbidity. Functional aspects such as gastric emptying might be more frequent after pCT
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