Among patients with resectable esophageal adenocarcinoma, tumor stage after completion of neoadjuvant chemotherapy is a much more important predictor of survival than is initial tumor stage at presentation, according to a report published online July 28 in Journal of Clinical Oncology.
Researchers analyzed data regarding 584 consecutive resections for adenocarcinoma of the esophagus or esophagogastric junction during a 10-year period at two high-volume centers in London. Tumors were initially staged by a multidisciplinary team after patients were evaluated via endoscopy, computed tomography (CT), endoscopic ultrasound, and/or latterly fluorodeoxyglucose positron emission tomography, said Dr. Andrew R. Davies of the department of surgery, St. Thomas’ Hospital, London, and his associates.
A total of 184 patients underwent immediate surgical resection, while 400 had neoadjuvant chemotherapy followed by surgical resection. The predominant chemotherapy regimens were cisplatin and fluorouracil; epirubicin, cisplatin, and fluorouracil; or epirubicin, cisplatin, and capecitabine. For the majority of patients, two, three, or four cycles of neoadjuvant treatment were administered.
Tumors were restaged via CT after chemotherapy was completed; cancers in 175 of these patients (44%) were downstaged. Compared with patients whose esophageal cancers were not downstaged, these treatment responders showed greatly improved rates of 5-year survival (52.5% vs 12.6%; P less than .001)), higher rates of clear surgical margins at resection (74% vs 40%; P less than .001), lower rates of isolated local recurrence (6% vs 13%; P = .03), and lower rates of systemic metastatic recurrence (19% vs 29%; P = .027). The chemotherapy regimen did not significantly affect the likelihood of tumor downstaging.
These findings show that “pathological stage after chemotherapy strongly dictates prognosis, whereas the initial pretreatment staging does this only to a limited extent. This indicates that advanced diagnostic staging procedures (e.g., PET-CT, esophageal ultrasound, or MRI) should be used after neoadjuvant chemotherapy. The major clinical decision making should be based on this staging rather than the initial staging. The main purpose of initial staging would be to identify any distant metastases (thus precluding curatively intended treatment) and to provide a baseline from which to compare the response to treatment. This would be a novel clinical approach that might improve clinical decision making and survival after curatively intended treatment,” Dr. Davies and his colleagues said (J. Clin. Oncol. 2014 July 28 [doi:10.1200/JCO.2014.55.9070]).
“No previous study has been able to quantify the local and systemic downstaging effects of systemic therapy in this manner and combine it with robust long-term follow-up data,” they noted.
This study was supported by the Swedish Research Council, the Swedish Cancer Society, and the National Institute of Health Research, Royal Marsden /Institute of Cancer Research Biomedical Research Center. Dr. Davies’ associates reported ties to Eli Lilly, Nestle, Astellas, Roche, Sanofi-Aventis, AstraZeneca, Amgen, Merck, Celgene, and Novartis.
By: MARY ANN MOON
