Predictive value of restaging after induction concurrent chemoradiotherapy for locoregionally advanced adenocarcinoma of the esophagus and gastroesophageal junction

Abstract

Background: Current treatment protocols for locoregionally advanced esophageal cancer add concurrent chemoradiotherapy to surgical resection in an effort to improve curative potential. These approaches are intensive and toxic. This retrospective review was undertaken to identify clinical features after concurrent chemoradiotherapy that might predict for treatment failure.

Methods: 155 patients with locoregionally advanced adenocarcinoma of the esophagus/gastroesophageal junction were treated with concurrent chemoradiation with 96 hour infusions of cisplatin (20mg/m²/day) and fluorouracil (1,000mg/m²/day) beginning on day 1 of radiation (30 Gy @ 1.5 Gy bid). Surgery followed in 4-6 weeks with identical concurrent chemotherapy planned post-operatively. 75 patients also received 2 years of oral gefitinib Pretreatment staging evaluation was obtained in all patients which included a medical history, physical examination, complete blood count, serum chemistries, chest radiograph, computed tomographic scans of the chest and abdomen, pulmonary function studies, esophagogastroduodenoscopy (EGD) with biopsy, endoscopic ultrasound (EUS), and bronchoscopy if indicated by symptomatology, or by the extent or location of the primary lesion. This also included assessment of symptomatic dysphagia. Approximately 3 weeks after completing induction chemoradiation, all patients underwent restaging evaluation. Using this pretreatment and posttreatment staging information, prognostic factors for freedom from recurrence and overall survival were identified.

Results: The 36 months freedom from recurrence was 31% and overall survival 32%. Post-induction change in EGD tumor length and EUS TNM stage did not correlate with outcome. Resolution of symptomatic dysphagia, which occurred in 86%, was the strongest predictor for freedom from recurrence (p<0.001) and overall survival (p<0.001).

Conclusions: EGD and EUS restaging of locoregional disease after induction concurrent chemoradiotherapy did not help to predict recurrence. The persistence symptomatic dysphagia, when coupled with advanced pretreatment stage, is ominous and predicts for incurable disease.  Subsequent therapy should be considered palliative.