INTEGRATION OF SURGERY IN MULTIMODALITY THERAPY FOR ESOPHAGEAL CANCER

Background: While adding chemotherapy to radiation for the treatment o f esophageal cancers has been shown to be beneficial, surgery usually follows treatment or is omitted. In either case, regional control rema ins problematic, The purpose of this study was to test the feasibility of using chemotherapy and radiation following surgery in the treatmen t of of esophageal cancer and to assess the impact of this approach on regional control and survival. Patients and Methods: Twenty-five pati ents with esophageal cancer were treated in a phase I pilot protocol c onsisting of initial esophagectomy with gastroesophagostomy and subseq uent combined chemotherapy and radiation, Chemotherapy consisted of ci splatin given on day 1 and 5-fluorouracil (FU) on days 1-5 by continuo us infusion. Radiation therapy was administered in varying fractionati on schedules of once or twice daily concomitantly with the chemotherap y. Treatment was repeated every other week for two to four cycles. Med ian follow-up was 42 months. Results: Acute toxicities (mucositis and cytopenias) were common but not worse than grade 3. Higher doses of 50 Gy with 2 Gy b.i.d. hyperfractionation caused late complications in f our of 10 patients, (two lethal). Control of local disease for all pat ients was excellent with only two known and two possible local recurre nces (16%) but distant metastases were common (46%). Disease-free surv ival was 58 and 30% at 1 and 2 years, respectively. Survival was 58 an d 32% at 1 and 2 years, respectively (median survival, 19 months). Con clusion: The local control rate and survival were better than those in our historical experience with cisplatin and 5-FU chemotherapy and ra diation given prior to surgery. A dose-fractionation schedule of <2 Gy up to a total of 50 Gy b.i.d. is recommended to avoid late adverse ef fects. The role of surgery will be defined by randomized studies. Bett er systemic therapy is needed to impact on systemic failure.