Hypothesis: Patients receiving neoadjuvant chemoradiotherapy followed by surgery (CRS) undergo downstaging of their tumor and have improved survival when compared with patients undergoing surgery followed by adjuvant chemoradiotherapy (SCR). Design: Retrospective study. Setting: Tertiary-care university medical center. Patients: One hundred twenty-three patients with squamous cell carcinoma and adenocarcinoma of the esophagus underwent Ivor-Lewis esophagectomy from January 1, 1990, through December 31, 2001. Of these, 31 received CRS; 27, SCR; and 65, surgery alone. Interventions: Patients were candidates for neoadjuvant or adjuvant therapy if they had locally advanced disease (T3/T4 NO or any T stage with N1). Neoadjuvant and adjuvant therapies were nonrandomized and based on the preference of the treating oncologist and surgeon. Main outcome Measurements: Pathological downstaging was analyzed in the patients receiving CRS. Operative mortality, postoperative morbidity, median survival, and overall survival were compared between the CRS and SCR groups. Results: Pathological downstaging (as characterized by TNM staging) was observed in 20 (64%) of the patients receiving CRS. Complete pathological responses occurred in 5 (16%) of the patients undergoing CRS. No 30-day mortality was observed in either treatment group. No statistical difference in survival was observed between groups, although a trend suggested improved survival with neoadjuvant therapy (3-year survival in CRS and SCR groups was 45% and 22%, respectively; P=.15). Complete pathological responders in the CRS group had a 1-year survival of 80% compared with 29% in nonresponders (P=.25). No statistical differences were observed between groups in relation to blood loss, length of hospital stay, mortality, or morbidity. Conclusions: Neoadjuvant chemoradiotherapy effectively downstages cancer in patients with locally advanced esophageal. disease. Morbidity and operative mortality were not significantly different between patients receiving neoadjuvant and adjuvant therapy. The difference in overall survival between the 2 groups did not reach statistical significance, although a trend at 3 years was observed.
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