Role of Esophagectomy after Chemoradiation Therapy in Patients with Locally Advanced Squamous Cell Carcinoma: A Comparative Analysis Stratified by Clinical Response to Chemoradiation Therapy

Abstract

This study aimed to evaluate the long-term effect of esophagectomy in patients with esophageal squamous cell carcinoma (ESCC) by comparing the chemoradiotherapy (CRT)-only group and the trimodality treatment (TMT) group who received concurrent CRT followed by surgery. Materials and MethodsWe included 412 operable ESCC patients treated with TMT or CRT between January 2005 and December 2015. The oncological outcomes of the two groups were compared using a weighted Cox proportional-hazards model with inverse probability of treatment weighting (IPTW). ResultsThe median survival time was 64 and 32 months in the TMT (n=270) and CRT (n=142) groups, respectively (p < 0.001). After IPTW, the median overall survival (OS) remained significantly higher in the TMT group than in the CRT group (61 months vs. 32 months, p=0.016). Moreover, the TMT group showed a better local recurrence-free rate (LRFR, p < 0.001) and distant metastasis-free rate (p=0.007). In the subgroup of patients with clinical complete response (cCR), the OS was not significantly different between the two groups, both before and after IPTW adjustment (p=0.35 and p=0.93). However, among non-cCR patients, the OS was significantly higher in the TMT group (64% vs. 45%, p < 0.001). ConclusionIn patients with locally advanced ESCC, TMT was superior to CRT in terms of OS and LRFR.Such difference was more prominent in the non-cCR subgroup. In patients who achieved cCR, esophagectomy was effective in improving LRFR but not OS, suggesting that esophagectomy may be omitted in complete responders.

Comparison of clinical outcomes of conservative treatment and surgery for esophageal cancer patients who achieve a clinical complete response following neoadjuvant chemoradiotherapy: a systematic review and meta-analysis

“…Ultimately, 9 articles, comprising 749 patients, were deemed eligible for inclusion in our study. Among these articles, most came from Asia [3 from Korea ( 8 , 13 , 14 ); 1 from Taiwan/China ( 11 ), and 1 from Turkey ( 15 )], and 4 came from the West (1 each from Italy ( 10 ), the Netherlands ( 16 ), France ( 17 ), and Ireland ( 18 )]. In total, 333 and 416 patients were categorized into the nCRT and nCRT + S groups, respectively.…”

“…Similar to van der Wilk et al (16), we found that the 2-year OS and 5-year OS of patients in the nCRT + S group and those of patients in the nCRT group did not differ significantly. Of the 9 studies included in our metaanalysis, 6 included patients with ESCC, and among these 6 studies, 5 showed that conservative treatment could be adopted for patients with esophageal carcinoma who achieved a cCR after nCRT (10,11,(13)(14)(15). In the following paragraphs, we interpret our OS and DFS results from a clinical perspective.…”

“…Surgery can be used to expand the surgical region to radically remove the tumor, which can provide better local control than singular non-surgical therapy. Yu et al ( 14 ) reported that the 1- and 5-year local recurrence rates were 9% and 12%, respectively, in the nCRT + S group, and 28% and 41%, respectively, in the nCRT group. A prospective study by Park et al ( 13 ) showed that the surgery group tended to have better DFS than the non-surgery group (with 2-year DFS rates of 66.7% vs. 42.7%, respectively).…”

Patterns of care and prognostic evaluation for stage I–III upper esophageal squamous cell carcinoma: a population-based study

“…Previous studies have indicated that chemoradiotherapy should be selected as the initial larynx-preserving treatment and that surgery should be a treatment of choice for patients with non-complete response after chemoradiotherapy for cervical EC ( 18 , 30 ). Although the CROSS trial and NEOCRTEC5010 trial suggested that chemoradiotherapy followed by surgery showed significantly better survival compared to surgery alone for locally advanced ESCC ( 11 , 14 ), the superiority of trimodality therapy over definitive chemoradiotherapy is controversial, especially for patients with clinical complete response to chemoradiotherapy ( 31 ) and patients with proton beam radiotherapy ( 32 ). Interestingly, a retrospective study indicated that patients with upper EC had a significantly higher rate of complete response to chemoradiotherapy compared to patients with middle EC ( 33 ).…”

Unveiling Therapeutic Targets for Esophageal Cancer: A Comprehensive Review

“…For the treatment of EC, surgery is still the most effective single-modality therapy. The increased risk of relapse after esophagectomy has motivated researchers to look into multidisciplinary treatment options such as concurrent chemoradiotherapy (CCRT) with or without surgery [14]. However, the best treatment option for EC is still up for debate.…”