G. S. Chevrollier1, D. Giugliano1, F. Palazzo1, E. L. Rosato1, N. R. Evans1, A. C. Berger1 1Thomas Jefferson University,Department Of Surgery,Philadelphia, PA, USA
Introduction:
Despite advances in care, survival for patients with locally advanced esophageal cancer (EC) remains poor. It is known that patients who undergo neoadjuvant chemoradiation (nCRT) and have poor or no response (non-responders) have worse survival compared to those who respond. We sought to evaluate survival of patients who underwent nCRT compared to similarly-staged patients who underwent esophagectomy without nCRT (primary esophagectomy).
Methods:
Using our IRB-approved institutional esophagectomy database, we retrospectively identified all patients who underwent open or minimally invasive esophagectomy at our institution between January 1994 and June 2015. We separated patients into two groups: those who underwent nCRT (n=235) and those who underwent up-front esophagectomy with pathologic stage II or greater (primary esophagectomy, n=53). The neoadjuvant group was further separated into patients who were downstaged (responders, n=133) and those whose pathologic stage was the same or higher than their pre-nCRT clinical stage (non-responders, n=102). Overall and 5-year survival were compared between these three groups using Kaplan Meier survival curves and log-rank statistics, with significance set at p<0.05.
Results:
We identified 288 patients who met our inclusion criteria with an average age of 62 years. 53% of patients were male and 61% underwent open esophagectomy. The majority had adenocarcinoma (82%, n=236). Serious complication rates (grade 3 or higher according to the modified Clavien scale) were 28.4%, 26.3%, and 24.5% for non-responders, responders, and primary esophagectomy, respectively (p=NS). The primary esophagectomy and non-responder groups had equal numbers of stage II (49% vs. 53%) and stage III (42% vs. 45%) cancers. Median survival was 36.2 months in the downstaged group (95% CI 27.2-42.6 months), 19.3 months in the non-responder group (95% CI 15-23.3 months), and 27.1 months in the primary esophagectomy group (95%CI 21.6-54.7 months) (p= 0.029). Five-year survival was 42% in the downstaged group, 25.8% in the non-responder group (HR 1.5), and 32.1% in the primary esophagectomy group (HR 1.2) (p=0.029).
Conclusions:
Patients with EC who fail to respond to nCRT have decreased survival compared to those who respond and those who undergo up-front esophagectomy. Neoadjuvant therapy in non-responders may delay definitive therapy in the form of esophagectomy, and may also expose patients to unnecessary morbidity and increased costs associated with nCRT. Further research is needed to identify potential non-responders with advanced resectable EC in order to provide more individually tailored treatment and avoid potentially harmful neoadjuvant therapy and delayed time to esophagectomy.
