Survival Benefit of Surgery in Patients with Clinical T4 Esophageal Cancer Responded to Neoadjuvant Chemoradiotherapy/Radiotherapy

Abstract

<h3>Purpose/Objective(s)</h3> This study aimed to determine the long-term survival of patients with cT4 esophageal cancer (EC) and whether neoadjuvant chemoradiotherapy/radiotherapy plus surgery (nCRT/RT+S) is superior to definitive chemoradiotherapy/radiotherapy (dCRT/RT) in terms of survival in cT4 EC downstaged after nCRT/RT. <h3>Materials/Methods</h3> From 2002 to 2017, 726 patients with cT4 esophageal squamous cell carcinoma (ESCC) were retrospectively analyzed. Patients achieving clinical complete response (cCR) or partial response (PR) after 4-week radiotherapy (median dose, 40.71 Gy) and considered fit for surgery were offered esophagectomy. Of the 726 patients, 308 (42.4%) achieved cCR/PR, while 74 patients received subsequent surgery (nCRT/RT+S group), 234 patients received definitive radiotherapy (dCRT/RT group). <h3>Results</h3> Median follow-up was for 58.25 months. The 3-year OS and corresponding PFS for cT4 ESCC were 33.3% and 35.6%. Moreover, the 3-year OS and PFS were 54.8% and 48.5% in the nCRT/RT+S group vs. 30.0% and 22.1% in the dCRT/RT group (both p < 0.0001). For the patients who achieved cCR/PR, IPTW was used to adjust the confounding variables and reduce bias in two groups. The adjusted 3-year OS rates was 50.4% in the nCRT/RT+S group vs. 50.8% in the dCRT/RT group (p = 0.15); however, the adjusted 3-year PFS rates was significantly different between the two groups (49.0% vs. 38.3%, p = 0.0036). Postoperative complications occurred in 18 (24.3%) patients, and 2 (2.9%) patients died within 30 days of surgery. In dCRT/RT group, no patient had grade 5 radiation-related toxicity. <h3>Conclusion</h3> The OS of cT4 ESCC has been significantly improved after the use of 3D-RT/CRT. In cT4 EC downstaged after nCRT/RT, surgery improves PFS.