The role of multimodality therapy for resectable esophageal cancer

BACKGROUND: There is an increasing interest in the role of combined therapy to achieve longterm survival for patients with resectable esophageal neopl asms. Surgery provides excellent palliation with relatively low morbidity a nd mortality rates, but cure remains elusive. MATERIAL AND METHODS: From January 1988 to January 1998, a total of 137 pat ients met eligibility criteria for a combined multimodal therapy, prospecti ve, nonrandomized protocol of induction chemoradiation therapy followed by surgical resection, based on radiological and endoscopic assessment of the extension (all patients were initially considered to be at clinical stages I to III, locoregional). Consequently, patients with high grade Barrett's d ysplasia or any squamous carcinoma in situ (stage 0) and those with distant metastatic disease (stage IV) were excluded. Among this group, 48 operable patients with biopsy-proven esophageal cancer finally entered and complete d the protocol and are the sample of the present study. Multivariate logist ic regression models were used to identify risk factors for death or recurr ence. Actuarial survival was calculated since the beginning of the inductio n protocol by the Kaplan-Meier method, and comparisons between groups were made by the log-rank test. RESULTS: Mean age was 61.6 (range 45 to 71), and 72.9% were male. The major ity of the tumors (70.8%) were located at the lower third/ cardia and as ma ny as 18.8% were adenocarcinoma. After a mean of 7.5 weeks (range 5 to 12) after the completion of the induction phase, 68.7% underwent a transthoraci c esophagectomy and 31.3% a transhiatal esophagectomy. The in-hospital mort ality rate was 10.4% (5 patients). A complete response (no evidence of tumo r within the specimen: pT0) was achieved in 25% (12 patients). After a mean follow-up of 20.2 months, mean survival for the entire group was 18.2 mont hs (95% confidence interval 14 to 22). At the end of the study, 25% (12) re mained alive. Actuarial survival rates at 12, 23, and 37 months were 56.2%, 36,9%, and 21.9%, respectively. CONCLUSIONS: Esophageal resection after induction therapy seems to be relat ed to a slightly higher mortality rate compared with historical series, and for this reason, neoadjuvant therapy must be considered still experimental . However, no statistical significant difference in survival is showed in t hose cases with complete pathological response (pT0). Factors influencing s urvival are recurrence and age. Surgery alone remains the standard therapy for esophageal cancer. (C) 2000 by Excerpta Medica, Inc.