Treatment of Choice for Resectable Cervical Esophageal Cancer: Surgery and Definitive Chemoradiotherapy with or without Dose Escalation

Abstract

<h3>Purpose/Objective(s)</h3> Cervical esophageal cancer is rare subgroup which epicenter of tumor located between upper esophageal sphincter and sternum notch, for 5% to 10% of all esophageal cancers. Most of patients of cervical esophageal cancer needed hypopharyngectomy and laryngectomy for complete resection, pre-operative chemotherapy (CTx) or chemoradiotherapy (CRT) is needed, and even definitive CRT has been widely accepted treatment of choice for laryngeal preservation. We reviewed our institutional experiences to compare and tried to suggest the treatment directions for resectable cervical esophageal cancer. <h3>Materials/Methods</h3> A total of 197 patients who were diagnosed as cervical esophageal cancer without distant metastasis between January 2001 and December 2020 were identified. Of those, 47 patients were excluded in this study because of unresectable stage (e.g., initial stage T4 or extensive nodal stage), 100 patients had definitive chemoradiotherapy and 50 patients had surgery. In surgery group, 16 patients received preoperative treatment (CRT; 6 patients, CTx alone; 10 patients) and 16 patients received postoperative treatment (CRT; 6 patients, CTx alone, 6 patients, radiotherapy alone; 4 patients). Definitive CRT group patients were divided into high-dose group (≥59.4 Gy, n=71), and standard dose group (<59.4 Gy, n=29). <h3>Results</h3> The median follow-up was 30 months (5-225 months) for surviving patients. Of 50 patients with median age 63 in surgery group, 21 (42%), 9 (18%), 18 (36%), 2 (4%) patients were stage I, II, III and IV respectively. Patients in CRT group was statistically significant different in age (median 67) and stage as 19 (19%), 30 (30%), 44 (44%), 7 (7%) patients were stage I, II, III, IV. There was no statistical difference in overall survival (OS) (3-year OS: 61.2% vs 62.9%, p=0.976) and progression free survival (PFS) (3-year PFS: 47.5 % vs 53.0%, p=0.589). Treatment related toxicity (Grade≥2) were significantly higher in surgery group than CRT group (14(28%) vs 12 (12%), p=0.015), even only 6 patients received hypopharyngectomy and laryngectomy. In subgroup analysis between high-dose group and standard dose group, OS and loco-regional failure free survival (LRFS) was significantly higher in high-dose group (3-year OS: 65.4% vs 51.7%, p=0.046, 3-year LRFS 68.7% vs 42.5%). There was no significant difference between two group (High-dose group 9 (12.7%) vs Standard dose group 3 (10.3%), p=0.106). <h3>Conclusion</h3> There was no significant difference in OS and PFS between surgery and CRT group although surgery group had patient selection bias for patients with earlier stage and younger age. Also, LRFS were better with high-dose CRT than standard group which lead to better OS and consequently achieved favor OS in general CRT group. High dose RT was not associated with higher toxicity rate, mainly because recent intensity modulated RT could give higher dose while saving normal organ toxicity. Thus, high dose CRT should be considered as initial treatment for cervical esophagus than surgery.