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Utility of Radiation After Neoadjuvant Chemotherapy for Surgically Resectable Esophageal Cancer

  • Francis I. MacedoEmail author
  • Jose Wilson Mesquita-Neto
  • Kristin N. Kelly
  • Basem Azab
  • Danny Yakoub
  • Nipun B. Merchant
  • Alan S. Livingstone
  • Dido Franceschi
Thoracic Oncology

Abstract

Introduction

Neoadjuvant chemotherapy (NAC) ± radiation (NRT) is the “gold standard” approach for locally advanced esophageal cancer (EC). However, the benefits of RT on overall survival (OS) in patients with resectable EC undergoing neoadjuvant therapy followed by esophagectomy remain controversial.

Methods

The National Cancer Data Base was queried for patients with nonmetastatic EC between 2004 and 2014. Kaplan–Meier, log-rank, and Cox multivariable regression analysis were performed to analyze OS. Logistic regression analyzed factors associated with 90-day mortality, lymph node involvement, and complete pathological response (pCR).

Results

A total of 12,238 EC patients who underwent neoadjuvant therapy [neoadjuvant chemoradiation (NACR), 92.1% and NAC, 7.9%] followed by esophagectomy were included. OS was similar in patients undergoing NAC ± RT (35.9 vs. 37.6 mo, respectively, p = 0.393). pCR rate was 18.1% (19.2%, NACR vs. 6.3%, NAC, p < 0.001). NRT was an independent predictor for increased pCR (HR 2.593, p < 0.001). Patients with pCR had increased survival compared with those without pCR (62.3 vs. 34.4 mo, p < 0.001); however, no difference was found between NACR and NAC (61.7 mo vs. median not reached, p = 0.745) in pCR patients. In non-pCR patients, NAC had improved OS compared with NACR (37.3 vs. 30.8 mo, p = 0.002). NRT was associated with worse 90-day mortality (8.2% vs. 7.7%, HR1.872, p = 0.036) In Cox regression, NRT was an independent predictor of worse OS (HR 1.561, p < 0.001).

Conclusions

Neoadjuvant RT is associated with improved pCR rates; however, it had deleterious effects in short- and long-term survival. Also, patients who did not achieve pCR had worse OS after neoadjuvant RT.

Notes

Supplementary material

10434_2019_7788_MOESM1_ESM.docx (76 kb)
Supplementary material 1 (DOCX 76 kb)
10434_2019_7788_MOESM2_ESM.jpeg (76 kb)
Figure S1. Flow chart depicting cohort selection (JPEG 75 kb)
10434_2019_7788_MOESM3_ESM.jpg (822 kb)
Figure S2. Kaplan–Meier curves depicting overall survival in patients undergoing NACR or NAC according to pathological tumor stage. In patients with pT2, median OS was statistically superior in patients undergoing NAC compared to NACR (60.9 vs. 35.9 months, p = 0.002). For all remaining pathological T stages, there was similar OS between NAC and NACR (pT0: not reached vs. 53.9 months, p = 0.489; pT1: 62.7 vs. 45.8 months, p = 0.099; pT3: 26.1 vs. 25.3 months, p = 0.385 and pT4: 21.1 vs. 18.2 months, p = 0.066) (JPEG 822 kb)
10434_2019_7788_MOESM4_ESM.jpg (553 kb)
Figure S3. Kaplan–Meier Curves demonstrating similar overall survival in patients undergoing NACR or NAC according to histological type. A: Adenocarcinoma, NAC- 37.6 months vs. NACR- 35.5 months, p = 0.203). B: Squamous cell carcinoma: NAC-32.9 months vs. 40.7 months, p = 0.503 (JPEG 552 kb)

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Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Francis I. Macedo
    • 1
    Email author
  • Jose Wilson Mesquita-Neto
    • 2
  • Kristin N. Kelly
    • 3
  • Basem Azab
    • 4
  • Danny Yakoub
    • 5
  • Nipun B. Merchant
    • 3
  • Alan S. Livingstone
    • 3
  • Dido Franceschi
    • 3
  1. 1.Department of Surgery, North Florida Regional Medical CenterUniversity of Central Florida College of MedicineGainesvilleUSA
  2. 2.Department of SurgeryWayne State University School of MedicineDetroitUSA
  3. 3.Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, and Sylvester Comprehensive Cancer CenterUniversity of Miami Miller School of MedicineMiamiUSA
  4. 4.Sentara Careplex HospitalSentara Healthcare SystemHamptonUSA
  5. 5.Department of SurgeryUniversity of Tennessee School of MedicineMemphisUSA

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