Nonoperative therapy for squamous-cell cancer of the esophagus.

Abstract

Based on the surgical pathology and survival for patients in previous trials using a neoadjuvant program of chemotherapy (5-fluorouracil [5-FU]-cisplatin) and radiation (3,000 cGy) before surgery for squamous-cell cancer (SCC) of the esophagus, a nonoperative pilot trial was designed to test if survival and recurrence would differ from our historical controls if routine esophagectomy was eliminated. Twenty patients were treated. The protocol called for the delivery of 5-FU infusion (1,000 mg/m2/d X 4 d) days 1 to 4 and 29 to 32 with cisplatin (100 mg/m2) day 1 and 29 sandwiched around external beam radiation (3,000 cGy over 3 weeks). Mitomycin C (10 mg/m2) day 57 was administered with bleomycin infusion (20 U/d X 4 d) days 57 to 60 and 78 to 81. A radiation boost of 2,000 cGy was administered 200 cGy/d days 99 to 103 and 106 to 110. Clinical pulmonary toxicity forced withdrawal of bleomycin and mitomycin C in the last four patients treated; two further courses of 5-FU-cisplatin were administered instead. The median measurement of the 20 esophageal lesions by barium swallow was 7 cm. Four patients underwent salvage surgery to prevent life-threatening aspiration pneumonia. The median survival for the 20 patients is 22 months, with a range from 6 to 39+ months. The six patients clinically without cancer are alive 22+ to 39+ months (median, 35+ months). Three patients died manifesting only local (infield) recurrence; five died manifesting only distant recurrence; and five developed local and distant recurrence. While the toxicity of the four drug regimen as administered was prohibitive, the survival and quality of survival is superior to the regimen previously used, which routinely used surgery after preoperative chemotherapy and radiation.

Definitive chemoradiotherapy for patients with malignant stricture due to T3 or T4 squamous cell carcinoma of the oesophagus

“…The value of chemoradiotherapy for the treatment of unresectable oesophageal carcinoma remains controversial, and only a few clinical studies have been published since the 1980s (Leichman et al, 1984;Leichman et al, 1987;Poplin et al, 1987;Coia et al, 1991;Herskovic et al, 1992;Frorastiere et al, 1993;Poplin et al, 1994). Most patients in these studies had local -regional disease (UICC stage I or II).…”

“…Several investigators have reported successful results with these modalities, either with or without surgery, against local -regional carcinoma (Leichman et al, 1984;Leichman et al, 1987;Poplin et al, 1987;Coia et al, 1991;Frorastiere et al, 1993;Poplin et al, 1994). The combination of 5-fluorouracil (5-FU) and cisplatin (CDDP) has become a standard regimen, not only because of the clinical outcome but also because of the synergism between the two agents and their radiosensitising effects (Douple et al, 1980;Scanlon et al, 1986;Byfield, 1990).…”

Salvage Esophagectomy after Unsuccessful Curative Chemoradiotherapy for Squamous Cell Cancer of the Esophagus

“…There are, however, a small number of patients who can benefit from salvage surgery after nonresponse or recurrence following chemoradiotherapy. Coia et al [5, 6] and Leichmann et al [7] reported several cases (2 and 3, respectively) in larger series of medically treated patients.…”

“…Survival was greater than 9 months for 3 of them, including 1 who survived more than 3 years. Unfortunately, Leichmann et al [7] did not report survival times for their 3 cases.…”

Acute and Delayed Effects of Radiotherapy in Patients with oesophageal Squamous cell Carcinoma Treated with Chemotherapy, Surgery and Pre- and Postoperative Radiotherapy

“…Thus it is hardly surprising that attempts have been made to improve long-term prognosis by means of multimodal regimes (chemotherapy, radiotherapy and surgery), and in a number of phase 11 trials improvements have been obtained both in terms of palliation and survival rates (10)(11)(12)(13)(14). A randomired study has also shown that a combined approach to the treatment of oesophageal squamous cell carcinoma, using induction chemotherapy, radiotherapy and surgery, yielded better results both with regard to local control and to survival rates ( 15).…”