Complete pathologic response after neoadjuvant chemoradiotherapy for esophageal cancer is associated with enhanced survival

Abstract

Background: Neoadjuvant chemoradiotherapy followed by esophagogastrectomy has become the standard of care for patients with locally advanced esophageal cancer. This report analyzes our experience with this treatment approach.

Methods: From January 1998 through December 2003, all patients from a single institution receiving neoadjuvant chemoradiotherapy followed by esophagogastrectomy were reviewed for operative mortality, morbidity, long-term survival, and factors affecting survival. Only patients preoperatively staged with both computed tomographic scans and endoscopic ultrasound were included.

Results: There were 162 patients (142 men, 20 women), and the median age was 61 years (range, 22 to 81 years). Histopathology was adenocarcinoma in 143 patients and squamous cell in 19. Pretreatment clinical stage was II in 28 patients (17%), III in 111 (68%), and IV (M1a) in 23 (14%). Ivor Lewis esophagogastrectomy was the most common procedure, occurring in 132 patients. Operative mortality and morbidity was 4.9% and 37%, respectively. Pathologic response was complete in 42 patients (26%), near complete in 27 (17%), partial in 88 (54%), and unresectable in 5 (3%). Five-year survival for overall, complete, near complete, and partial response patients was 34%, 55%, 27%, and 27%, respectively (p = 0.013). Patients whose lymph nodes were rendered free of cancer showed improved overall and disease-free survival compared with patients having persistently positive lymph nodes (p = 0.019).

Conclusions: Esophagogastrectomy after neoadjuvant chemoradiotherapy can be performed with low mortality and morbidity. Patients with complete pathologic response have significantly improved long-term survival compared with patients with near complete and partial responses. Future efforts should be directed at understanding determinants of complete responses.

Fig 1

Probability of overall survival (death from any cause) in 154 operative survivors based on pretherapy stage. Zero time represents hospital discharge date. IIA versus IIB, p = 0.44; IIA versus III, p = 0.10; IIA versus IVA, p = 0.142.

Fig 2

Probability of overall survival (death from any cause) based on response to therapy after neoadjuvant chemoradiotherapy followed by surgical resection. Forty patients had complete pathologic response, 114 patients had some degree of residual tumor (near complete, partial pathologic response, or unresectable cancer). Zero time represents the hospital discharge date.

Fig 3

Probability of overall survival (death from any cause) based on response to therapy after neoadjuvant chemoradiotherapy followed by surgical resection. Zero time represents hospital discharge date. Complete versus near complete, p = 0.08; complete versus partial, p = 0.026; complete versus unresectable, p = 0.0002, near complete versus partial, p = 0.978. (Complete = complete pathologic response; Near complete = near complete pathologic response; Partial = partial pathologic response; Unresectable = unresectable cancer.)

Fig 4

Probability of overall survival (death from any cause) based on pathologic lymph node (LN) status in 149 operative survivors having neoadjuvant chemoradiotherapy followed by surgical resection. Zero time represents hospital discharge date.

Fig 5

Probability of disease-free survival (death from any cause) based on response to therapy in 149 operative survivors who underwent neoadjuvant chemoradiotherapy followed by surgical resection. Forty patients had a complete pathologic response, 109 patients had some degree of residual tumor present (either near complete or partial pathologic response). Zero time represents hospital discharge date.

Fig 6

Probability of disease-free survival (death from any cause) based on pathologic lymph node (LN) status in 149 operative survivors who underwent neoadjuvant chemoradiotherapy followed by surgical resection. Zero time represents hospital discharge date.