Does neoadjuvant chemoradiation downstage esophageal carcinoma?

Background: Neoadjuvant chemoradiotherapy is administered to patients with esophageal carcinoma with the belief that this will both downstage the tumo r and improve survival. Endoscopic ultrasound (EUS) is currently the most a ccurate method of staging esophageal cancer for tumor (T) and lymph node (N ) status. Because both EUS and neoadjuvant therapy for esophageal carcinoma are relatively new, there are few data examining the relationship between EUS stage and histological stage (the stage after resection) in patients re ceiving neoadjuvant therapy. Methods: To determine the effect of neoadjuvant chemoradiotherapy on T and N stage as determined by EUS,we retrospectively compared two groups of pati ents with esophageal cancer staged by EUS. One group (33 patients) underwen t neoadjuvant therapy (Walsh protocol: 5-fluorouracil, cisplatin, and 4000 mds of external beam radiation) followed by resection. The second group (22 patients), a control group, underwent resection without neoadjuvant therap y. We then compared histological stage to determine if there was a downstag ing in the patients receiving neoadjuvant therapy. Survival was evaluated a s well. Results: EUS accurately predicted histologic stage. In the control group EU S overestimated T stage in 3 of 22 (13%), underestimated N stage in 2 of 22 (9%), and overestimated N stage in 2 of 22 (9%) of patients. Preoperative radiochemotherapy downstaged (preoperative EUS stage versus pathologic spec imen) 12 of 33 (36%) Of patients whereas only 1 of 22 (5%) of patients in t he control group was downstaged. Complete response (no tumor found in the s urgical specimen) was observed in 5 of 33 (15%) of patients receiving radio chemotherapy. Survival was prolonged significantly in patients receiving ra diochemotherapy: 20.6 months versus 9.6 months for those (stage II or III) patients not receiving radiochemotherapy (P < 0.01). Operative time, operat ive blood loss, and length of stay were not significantly different between groups. Perioperative mortality was higher in the radiochemotherapy group (13%) compared with the no radiochemotherapy group (5%) but did not achieve statistical significance. Conclusions: EUS accurately stages esophageal carcinoma. Neoadjuvant radioc hemotherapy downstages esophageal carcinoma for T and N status. In our nonr andomized study, neoadjuvant therapy conferred a significant survival advan tage. Operative risk appears to be increased in patients receiving neoadjuv ant radiochemotherapy prior to esophagectomy. (C) 2001 Excerpta Medica, Inc . All rights reserved.