Neoadjuvant therapy for esophageal cancer: Standard of care or elusive myth?

Although surgical resection as the sole treatment modality for esophageal c arcinoma has historically been associated with poor survival rates, improve ments have recently been reported using varied neoadjuvant chemo-radiation protocols. This study evaluates the outcome of patients undergoing surgery for esophageal carcinoma at the University of Miami/Jackson Memorial Hospit al between July 1991 and June 1996. Seventy-two patients underwent esophage al resection; 51 males and 21 females with a median age of 62.5 years (rang e = 42-82). Histology was equally distributed between adenocarcinoma (36 pa tients; 50%) and squamous cell carcinoma (36 patients; 50%). Pathological s tage distribution consisted of 6 stage 0 (8%), 10 stage I (14%), 23 stage I I (32%), 31 stage III (43%), and 2 stage IV (3%) lesions. Patients were div ided into three groups according to the type of preoperative treatment; Gro up 1 (n = 44); surgery alone; Group 2 (n = 18); neoadjuvant 5-fluorouracil based chemotherapy, and Group 3 (n = 9); neoadjuvant 5-fluorouracil based c hemotherapy in conjunction with external beam radiation (XRT). One patient received preoperative XRT alone. All survivors were followed for a minimum of 1 year and statistical analysis was performed using Kaplan-Meier curves, log-rank, and chi-square tests. In the 28 patients receiving any form of n eoadjuvant therapy only one patient had a pathological complete response (C R) (3.5%). The overall 5 year and median survival rates were 18 per cent an d 20.5 months (range = 0-73), respectively. Individual treatment group surv ival rates at 5 years were 28% for Group 1; 21% for Group 2; and 0% for Gro up 3, showing no survival difference between Groups 1 and 2; Group 3 fared significantly worse than the other two, probably as a result of the high op erative mortality in this group. These results indicate that surgical resec tion continues to be an important treatment modality for esophageal carcino ma. Neoadjuvant chemotherapy in our experience failed to improve these surv ival rates and pre-operative chemoradiation was associated with a high peri operative mortality rate. Chemotherapy regimens with higher CRs may further improve these survival rates.