In patients with locally advanced esophageal squamous cell carcinoma (ESCC) undergoing minimally invasive esophagectomy, neoadjuvant chemoradiotherapy improves histopathologic outcomes compared with chemotherapy alone, with similar safety results, according to results of a study published today in JAMA Surgery.
"Esophagectomy remains the cornerstone of current therapy for esophageal cancer, one of the most common cancers worldwide," write the investigators, led by first author Hao Wang, MD, a cardiothoracic surgeon at Zhongshan Hospital of Fudan University in Shanghai, China. "However, the surgery alone is usually accompanied by high recurrence or metastasis rates with poor survival among patients with locally advanced esophageal cancer. Therefore, multidisciplinary therapy has been strongly recommended to improve the prognosis."
Dr. Wang and colleagues investigated the efficacy and safety of neoadjuvant chemoradiotherapy in 264 patients with locally advanced ESCC undergoing minimally invasive esophagectomy. Patients were randomized in a 1:1 ratio to receive chemotherapy consisting of 135 mg/m2 paclitaxel plus 75 mg/m2 cisplatin on day 1; or 50 mg/m2 paclitaxel plus 25 mg/m2 cisplatin on days 1, 8, 15, and 22, in combination with 40 Gy of concurrent radiotherapy, both followed by minimally invasive esophagectomy performed via thoracoscopy or laparoscopy after approximately six weeks of neoadjuvant therapy. The primary end point was overall survival at three years, with secondary end points of postoperative complications, mortality, postoperative pathologic outcomes, recurrence-free survival, and quality of life.
Patients receiving neoadjuvant chemoradiotherapy experienced a higher rate of negative lymph nodes compared with those receiving chemotherapy alone (66.1% vs 46.2%), as well as an improved rate of pathologic complete response, with 35.7% of patients in the neoadjuvant chemoradiotherapy group having 0% residual tumor after treatment versus 3.8% of those in the chemotherapy group. Rates of R0 resection (microscopically margin-negative resection with no gross or microscopic tumor remaining in the primary tumor bed) were similar between treatment arms (97.3% vs 96.2%). Perioperative mortality at 90 days was not statistically different in the neoadjuvant chemoradiotherapy group (3.5% vs 2.8%), nor was postoperative morbidity (47.4% vs 42.6%). Patients receiving neoadjuvant chemoradiotherapy did not experience a significant difference in one-year overall survival compared with those receiving chemotherapy alone (87.1% vs 82.6%), but did have a significantly lower rate of death due to tumor progression or recurrence (6.8% vs 14.4%). Deaths from nontumor causes were similar between the chemoradiotherapy and chemotherapy groups (6.8% vs 3.0%).
"This clinical trial showed that neoadjuvant chemoradiotherapy followed by minimally invasive esophagectomy could result in a better histopathologic outcome, as well as similar morbidity and mortality rates, compared with neoadjuvant chemotherapy," conclude Dr. Wang and colleagues. "It is worth observing the long-term survival benefit of neoadjuvant chemoradiotherapy versus chemotherapy in the follow-up."
For More Information
Wang H, Tang H, Fang Y, et al (2021). Morbidity and mortality of patients who underwent minimally invasive esophagectomy after neoadjuvant chemoradiotherapy vs neoadjuvant chemotherapy for locally advanced esophageal squamous cell carcinoma: a randomized clinical trial. JAMA Surg. [Epub ahead of print] DOI:10.1001/jamasurg.2021.0133
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