Trimodality treatment (TMT) for locally advanced esophageal cancer in Pakistan; Analysis of prognostic factors influencing survival

Abstract

15185 Background: The prognosis of patients with locally advanced esophageal cancer is poor. TMT for locally advanced esophageal cancer is being utilized with increasing frequency. In this study, we investigate the prognostic factors influencing survival in patients with locally advanced esophageal cancer following TMT. Methods: The study included 22 patients with esophageal carcinoma treated between January 2003 and December 2005 at Shaukat Khanum Memorial Hospital and Research Centre. Median age was 49 years (range 26 - 68). There were 15 (68%) males and 7 (32%) females. All patients had EGD with biopsy and CT chest. Twelve (54.5%) had squamous cell carcinoma and 10 (45.5%) patients had adenocarcinoma. Five patients (23%) had tumour in the middle third and 17 (77%) had lower/gastroesophageal lesions. Preoperative radiation consisted of 50.4 Gy / 28 fractions with concomitant chemotherapy day 1 and 29 (Cisplatin 75 mg/m2 day 1 and infusional 5FU 1000 mg/m2 day 1–5). Esophagectomy was done at 6 - 12 weeks following chemoradiation. The pathologic down-staging was evaluated by the 5-score tumor regression grade (TRG) of Mandard. Results: Post TMT pathologic TNM stage was; Stage 0 in 8 pts (36%), stage II in 5 pts (23%) and stage III in 9 pts (41%). 13 (59%) pts had R0 and 9 (41%) pts had R1 resection. The 4-year disease free survival was 29% with a median survival of 19 months. The number of patients with TRG score 1, 2, 3, 4 and 5 were 7 (32%), 4 (18%), 5 (23%), 2 (9%) and 4 (18%) respectively. Tumor regression grade 1–2 (p=.0016) and negative circumferential margins >2 mm (p=.0019) had a positive influence on DFS. Age (< 50 vs ≥ 50 years), sex, hemoglobin at presentation (≤ 12 vs > 12 gm/dl), tumor site (middle vs lower/GE junction), pathological nodal status (node positive vs node negative) and histological subtype (squamous cell vs adenocarcinoma) did not influence survival (p= 0.92, p= 0.82, p= 0.69, p= 0.79, p= 0.41 and p= 0.32 respectively). Conclusions: TMT results in prolonged disease free survival in patients with complete response or microscopic residual foci (TRG 1–2). Positive or circumferential margins <2mm is associated with poor prognosis. No significant financial relationships to disclose.