Neoadjuvant chemoradiotherapy followed by esophagectomy for initially resectable squamous cell carcinoma of the esophagus with multiple lymph node metastasis

Abstract

Neoadjuvant chemoradiotherapy (CRT) was expected to improve surgical curability and prognosis for advanced esophageal cancer. However, the clinical efficacy of neoadjuvant CRT followed by esophagectomy with three-field lymphadenectomy (3FL) for initially resectable esophageal squamous cell carcinoma (SCC) remains unclear. Since 1998, we have defined the status of metastases to five or more nodes, or nodal metastases present in all three fields as multiple lymph node metastasis, which was previously shown to be associated with poor prognosis. Between 1998 and 2002, 83 patients with initially resectable esophageal SCC were prospectively allocated into two groups, according to the clinical status of nodal metastasis. Nineteen patients clinically accompanied by multiple lymph node metastasis initially underwent neoadjuvant CRT followed by curative esophagectomy with 3FL (CRT group). The other 64 patients clinically without multiple lymph node metastasis immediately received curative esophagectomy with 3FL (control group). Although the overall morbidity rate was significantly higher in the CRT group, no in-hospital death occurred in either group. Patients without pathologic multiple lymph node metastasis in the CRT group showed a significantly better disease-free survival rate than either patients pathologically with multiple lymph node metastasis in the control group or those in the CRT group. However, the differences in the overall survival rate among the groups were not significant. Thus, the significant survival benefit by neoadjuvant CRT in addition to esophagectomy with 3FL was not confirmed, although it may have been advantageous, without increase in mortality, to at least some patients who responded well to neoadjuvant CRT. Therefore, neoadjuvant CRT can be an initial treatment of choice for resectable esophageal SCC clinically with multiple lymph node metastasis. The prediction of response to CRT and the development of alternative treatment for hematogenous recurrence could achieve a further survival benefit of this trimodality treatment.

Apparent Diffusion Coefficient Values Measured by Diffusion-Weighted Imaging Predict Chemoradiotherapeutic Effect for Advanced Esophageal Cancer

“…The CRT protocol was applied as described previously [23]. All 80 patients underwent CRT treated with cisplatin (CDDP), 5-fluorouracil (5-FU) and 40-Gy irradiation.…”

Aspectos atuais da terapêutica neo-adjuvante no carcinoma epidermóide do esôfago: revisão da literatura

“…Neste estudo não-randomizado, houve tendência para sobrevida melhor no grupo da quimioradioterapia neo-adjuvante. Nabeya et al 21 também em 2005, em estudo prospectivo não randomizado no Japão, avaliaram o efeito da quimioradioterapia neo-adjuvante (5-fluorouracil + cisplatina + 46 Gy radioterapia concomitantes) na esofagectomia com linfadenectomia em três campos. Entre 1998 e 2002, 83 pacientes com CEC de esôfago inicialmente ressecável foram prospectivamente alocados em dois grupos, de acordo com o estádio clínico da metástase linfonodal.…”

Utility of preoperative chemoradiotherapy for advanced esophageal carcinoma

“…There have been reports on intraoperative and postoperative complications after NACRT (postoperative pneumo- nia, MRSA enteritis, arrhythmia, pulmonary edema, ruptured suture, and increased difficulty of intraoperative techniques). [24][25][26][27] In the NACRT (+) group, the prognosis was significantly better in cases of grade 2 and grade 3, with marked histological improvement, than in those with grade 0 and grade 1 with little histological improvement (P = 0.001805) (Fig. 2).…”

“…NAC is carried out because it is expected to provide local control and additive effects on the outcomes of surgery, but its utility in terms of an improvement in prognosis has been unclear, as reported from Western countries. [11][12][13][14][15][16][24][25][26][28][29][30] Neoadjuvant chemoradiotherapy is aimed at: (i) improving the resection rate by local control of the primary lesion; (ii) controlling regional lymph node metastasis; and (iii) inhibiting distant micrometastasis. Of these goals, control of the regional lymph nodes is thought to be more important than an improvement in the resection rate; modifications of the irradiation field and irradiation method in NACRT, as well as surgical techniques, are expected to improve treatment outcomes of this trimodality (NACRT+ surgery).…”