Comparing Paclitaxel/Cisplatin and Cisplatin/5-fluorouracil in Neo-CRT for ESCC

Study Overview
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Brief Summary
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This clinical trial has two stages: phase II and phase III. Eligible patients will be randomized 1:1 to the two arms: paclitaxel plus cisplatin and cisplatin plus 5-fluorouracil. The phase II stage will enroll 128 patients, 64 patients for each arm. The endpoint of the phase II stage is complete pathological response (pCR). If the endpoint, i.e., the significant improvement of pCR rate, is met, the clinical trial will proceed to the phase III stage, in which 120 more patients will be enrolled. The estimated enrollment time is four years with 3 more years of follow-up after completing enrollment. The primary endpoint of the clinical trial is overall survival, and the secondary endpoints include clinical response, disease free survival, operation rate, complete resection rate, tumor regression rate, hospital stay days after surgery, safety and toxicity, and quality of life.

Detailed Description
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Stage 1: Neoadjuvant chemoradiation (CRT): Stage 2: Evaluation of clinical responses Evaluation will be done at 3±1 weeks after completing the last fraction of radiotherapy. Evaluation will be performed with panendoscopy, endoscopic ultrasonography (EUS), computed tomography (CT), and positron emission tomography (PET). Stage 3: Surgery Patients will receive esophagectomy with two field lymph node dissection unless: A. Patients become medically unfit for surgery. B. Tumor becomes metastatic or unresectable. C. Patients refuse surgery. Patients who do not receive surgery will go on a second section of CRT: A. Radiation: 180cGy/fraction, once daily, 5 days a week, up to a total of 6,300cGy. B. Arm A: i. T: Paclitaxel 50 mg/m2, 1h IVF, weekly, week 1 to week 3 during CRT. ii. P: Cisplatin 30 mg/m2, 2 h IVF, weekly following paclitaxel, week 1 to week 3 during CRT. C. Arm B: i. P: Cisplatin 75 mg/m2, 2 h IVF, on day 1 of week 1 during CRT. ii. F: 5-FU 1,000 mg/m2, 24 h IVF, on day 1, 2, 3, 4 of week 1 during CRT. Patients, who receive surgery with R2 resection or the pathology showing positive margins or extracapsular invasion of regional lymph nodes, will also receive the second section of CRT described in above-mentioned stage 3-2.

Official Title
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A Randomized Phase II/III Study of Paclitaxel/Cisplatin Versus Cisplatin/5-fluorouracil in Neoadjuvant Chemoradiation Followed by Surgery for Patients With Locally Advanced Esophageal Squamous Cell Carcinoma (ESCC)

Conditions
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Esophageal Squamous Cell Carcinoma, Chemoradiation

Intervention / Treatment
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* Drug: neoadjuvant chemoradiation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Pathologically proven squamous cell carcinoma of the intrathoracic esophagus. Locally advanced disease, which is defined by the TNM system of the American Joint Committee on Cancer (AJCC) Cancer Staging System (7th edition), fulfilling one of the following criteria as determined by endoscopic ultrasound, computed tomography, bronchoscopy and positron emission tomography: A. T3/4a, N0, M0; B. T1-3, N1-3, M0; Tumor length longitudinal ≤ 8cm and radial ≤ 5cm. The tumor must not extend more than 2cm into the stomach. The tumor must not involve cervical esophagus. No invasion of the tracheobronchial tree or presence of tracheoesophageal fistula. Age ≥ 20 and ≤ 75 years old. Performance status ECOG 0 2. Adequate bone marrow reserves, defined as: A. white blood cells (WBC) ≥ 4,000/µl or neutrophil count (ANC) ≥ 2,000/µl; B. platelets ≥ 100,000/µl. Adequate liver function reserves, defined as: A. hepatic transaminases ≤ 2.5 x upper limit of normal (ULN); B. serum total bilirubin ≤ 2.0 x upper limit of normal (ULN). Adequate renal function: Creatinine ≤1.5 x upper normal limit or estimated creatinine clearance ≥ 50 ml/min (estimated by Cockcroft-Gault formulation) Written informed consent. Patients must be able to fill in quality of life questionnaires. Exclusion Criteria: Adenocarcinoma. Previous thoracic irradiation. Previous systemic chemotherapy Synchronously diagnosed squamous cell carcinoma of aerodigestive way, other than esophageal cancer. Prior malignancy, except for the following: A. adequately treated basal cell or squamous cell skin cancer; B. in-situ cervical cancer; C. a cured malignancy more than 5 years prior to enrollment. Significant co-morbid disease, which prohibits the conduction of chemotherapy, concurrent chemo- radiotherapy, or radical surgery, such as active systemic infection, symptomatic cardiac or pulmonary disease, or psychiatric disorders. Documented myocardial infarction within the 6 months preceding registration (pretreatment ECG evidence of infarct only will not exclude patients). Patients with a history of significant ventricular arrhythmia requiring medication. Patients with a history of 2nd or 3rd degree heart block. Pre-existing motor or sensory neurotoxicity greater than grade 1. Patients with prior allergic reactions to drug containing Cremophor, such as teniposide or cyclosporine. Weight loss > 15%. Dementia or altered mental status that would prohibit the understanding and completion of informed consent and questionnaires. Estimated life expectancy less than 3 months.

Ages Eligible for Study
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Minimum Age: 20 Years
Maximum Age: 75 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: paclitaxel plus cisplatin<br>A. T: Paclitaxel 50 mg/m2, 1h IVF, weekly, week 1 to week 5 during CRT. B. P: Cisplatin 30 mg/m2, 2 h IVF, weekly following paclitaxel, week 1 to week 5 during CRT. | Drug: neoadjuvant chemoradiation<br>* Neoadjuvant chemoradiation: Radiation: 180cGy/fraction, once daily, 5 days a week, to a total of 4,500cGy. Chemotherapy: Arm A or Arm B Surgery: esophagectomy and 3-fields lymph node dissection<br>* Other names: esophagectomy;|
| Active Comparator: cisplatin plus 5-fluorouracil<br>A. P: Cisplatin 75 mg/m2, 2 h IVF, on day 1 of week 1 and week 5 during CRT. B. F: 5-FU 1,000 mg/m2, 24 h IVF, on day 1, 2, 3, 4 of week 1 and week 5 during CRT. | Drug: neoadjuvant chemoradiation<br>* Neoadjuvant chemoradiation: Radiation: 180cGy/fraction, once daily, 5 days a week, to a total of 4,500cGy. Chemotherapy: Arm A or Arm B Surgery: esophagectomy and 3-fields lymph node dissection<br>* Other names: esophagectomy;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| pathological complete response | No cancer cells in primary tumor and all lymph nodes resected are observed by pathologists | 2 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Overall survival | Time from enrollment to death | 4 years | 
| disease free survival | From the day of surgery with R0 resection to recurrence or death of any reasons | 4 years | 
| clinical response | The clinical response evaluation for the effect of neoadjuvant CRT will be done around 3±1 weeks after completing CRT. Evaluation will be performed with panendoscopy, EUS, CT, and PET. Clinical responses assessment will include: Overall clinical response according to RECIST1.1 and Japanese Esophageal Society (JES) Endoscopic response criteria according to JES Metabolic response evaluated by PET | 2 years | 
| operation rate | The ratio of the number of patients who receive surgery over the number of patients enrolled | 2 years | 
| R0 resection rate | The ratio of the number of patients with surgical R0 resection over the number of patients who receive surgery | 2 years | 
| tumor regression grade | A 4-tiered tumor regression grading (TRG) system will be used according to the extent of residual carcinoma in the whole tumor area of the esophageal specimen. TRG 1: no residual carcinoma. TRG 2: 1%- 10% residual carcinoma. TRG 3: 11%- 50% residual carcinoma. TRG 4: >50% residual carcinoma | 2 years | 
| The total score of participants of both arms will be analyzed and compared. | By World Health Organization Quality of Life Brief Version (WHOQOL-BREF) Taiwan version (2005), quality of life will be assessed at enrollment, at the end of neoadjuvant CRT, and 3 months after surgery. There are 28 subscales in the questionnaire. Each subscale has 5 scores from 1 (the worst) to 5 (the best). The scores of each subscale are summed to be a total score. | 2 years | 
| Number of participants with treatment-related adverse events as assessed by the NCI Common Toxicity Criteria (CTC) | By the NCI Common Toxicity Criteria (CTC), version 4.0., number of participants with treatment-related adverse events, all grades and grade 3/4, will be assessed. | 2 years |