Neoadjuvant chemotherapy for locally advanced squamous cell carcinoma of esophagus: Clinical profile and outcomes from tertiary care cancer centre
Authors: N. Kumar, S. Deo, N. Shukla, S. Bhoriwal, A. Sharma, R. Pramanik, R. Sahoo, S. Kumar
Journal: Annals of Oncology (2018)

Introduction: Esophageal cancer is the sixth most common malignancy in India. Squamous cell carcinoma (SCC) is the most common histology in the Indian subcontinent. Despite recent advances in the curative treatment of esophageal cancers, the benefit of neoadjuvant chemotherapy is quite limited and a definitive statement on the optimum perioperative treatment in terms of survival is still absent. Results from most of the trials from developed world would not be extrapolated in all patients. The multimodality approach for the carcinoma esophagus needs to be rethinking in the perspective of cost-effectiveness, regional biological and economic. In this study, we analyzed clinical profiles and both surgical and pathological outcomes of patients treated with curative surgery after neoadjuvant chemotherapy in our institute. Methods: Retrospective analysis of prospective maintained esophageal cancer computerised database was performed from 2013 to 2017. Patients with biopsy-proven squamous cell carcinoma of esophagus who underwent curative surgery after preoperative radiotherapy were included in the study. All patients with potentially resectable disease on imaging received 3 cycles of neo-adjuvant chemotherapy either cisplatin+5FU or paclitaxel +carboplatin. Esophagectomy performed 3-4 weeks after the completion of chemotherapy. Results: Total 52 patients with squamous cell carcinoma of esophagus underwent curative surgery during the study period. The most common presenting symptom was dysphagia in 48 (92%) patients. 22 (42%) patients had a history of weight loss (more than 10kgs). 28% of patients who present with absolute dysphagia required pre-treatment feeding interventions to improve the nutritional condition. 60% had a locally advanced disease and 40% patients had extraesophageal spread. Most common intervention performed was upper GI endoscopy guided nasogastric tube insertion. In the neo-adjuvant chemotherapy regimen; 30 (58%) patients received cisplatin+ 5FU and paclitaxel +carboplatin was given in 22 (42%) of the patients. Radiological response was seen in 70%. Majority of patients (62%) had the performance score of ECOG 2. 28 (55%) patients underwent McKeown esophagectomy with two field lymphadenectomy, 12(23%) patients underwent Ivor Lewis, Transhiatal in 2(3%) patients and 10 (19%) became inoperable. Post-operative early and late morbidity was documented in 10% and 03% of patients respectively. Pathological complete response (pCR) was achieved in 39% of patients. Maximum pCR achieved with cisplatin+FU 13(43%) and 32% with paclitaxel+carboplatin. 8% had pathological lymph nodes. 4 patients received adjuvant Radiotherapy. The loco-regional relapse rate was noted in 07% and systemic recurrence in 04%. Conclusion: Management of esophageal cancer patients with poor nutritional and performance status is challenging. Neo-adjuvant chemotherapy for locally advanced squamous cell carcinoma of esophagus has good operability rate and pathological outcomes, which is comparable to the current standard Neo-adjuvant treatment. The better long-term outcome is achieved by careful selection and tailoring the multimodality treatments according to patients' conditions.