NEOADJUVANT CHEMORADIOTHERAPY AND SURGERY COMPARED WITH SURGERY ALONE IN SQUAMOUS CELL CARCINOMA OF THE ESOPHAGUS

ANDREOLLO, Nelson Adami; TERCIOTI Jr., Valdir; LOPES, Luiz Roberto; COELHO-NETO, João de Souza

doi:10.1590/S0004-28032013000200016

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Original Articles • Arq. Gastroenterol. 50 (2) • April-June 2013 • https://doi.org/10.1590/S0004-28032013000200016 linkcopy

NEOADJUVANT CHEMORADIOTHERAPY AND SURGERY COMPARED WITH SURGERY ALONE IN SQUAMOUS CELL CARCINOMA OF THE ESOPHAGUS

Radioterapia e quimioterapia neoadjuvantes e cirurgia comparado com a cirurgia no tratamento do carcinoma epidermoide do esôfago

SCIMAGO INSTITUTIONS RANKINGS

Context Despite progress in recent years in methods of diagnosis and surgical treatment of esophageal cancer, there is still controversy about the benefits from neoadjuvant chemoradiotherapy.

Objective To analise the survival of patients submitted to esophagectomy for squamous cell carcinoma of the esophagus with or without neoadjuvant chemoradiotherapy.

Method A retrospective, non-randomized study conducted using the medical charts of patients operated for squamous cell carcinoma of the esophagus at the School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil between 1979 and 2006. The Kaplan-Meier analysis was used to calculate survival curves and the log-rank test to compare data in each group. The significance level was settled as 5%.

Results A total of 123 patients were evaluated in this study, divided into three groups: I - 26 (21.2%) patients submitted to esophagectomy alone; II - 81 (65.8%) patients submitted to neoadjuvant radiotherapy plus esophagectomy and III - 16 (13%) patients submitted to neoadjuvant chemoradiotherapy plus esophagectomy. A statistically significant survival was recorded between the groups (log rank = 6.007; P = 0.05), survival being greatest in the group submitted to neoadjuvant chemoradiotherapy, followed by the group submitted to neoadjuvant radiotherapy compared to the group submitted to esophagectomy alone as the initial treatment of choice.

Conclusion Radiotherapy and chemotherapy neoadjuvants in patients with squamous cell carcinoma of the esophagus offers benefits and increases survival.

Esophageal neoplasms; Carcinoma, squamous cell; Esophagectomy; Chemotherapy, adjuvant; Radiotherapy, adjuvant

Stage	Surgery alone		Neoadjuvant radiotherapy		Neoadjuvant radiotherapy + chemotherapy
Stage	n	%	n	%	n	%
0	0	0	13	16.04	5	31.25
I	6	23.07	7	8.64	3	18.75
IIA	11	42.3	34	41.98	4	25
IIB	3	11.55	16	19.76	2	12.5
III	6	23.08	11	13.58	2	12.5
IV	0	0	0	0	0	0

Complications	Surgery alone		Neoadjuvant radiotherapy		Neoadjuvant radiotherapy + chemotherapy
Complications	n	%	n	%	n	%
Intraoperative hemorrhage	0	0	4	4.93	1	6.25
Chest drainage	14	53.84	64	79	12	75
Bronchopneumonia	3	11.53	18	22.22	4	25
Anastomotic fistula/stenosis	12	46.15	32	39.5	11	6.25
Perioperative deaths	3	11.54	10	12.35	1	6.25

	Surgery	Surgery + radiotherapy	Surgery + radiotherapy + chemotherapy
No. of patients	23	71	15
No. of late deaths	12	23	3
Percentage of deaths	52.2	32.4	20.0
Mean time of follow-up (months)	32.43	65.75	87.28
Standard error	7.81	9.43	12.21
95% confidence interval	17.12-47.74	47.26-84.23	63.34–111.22
P-value	Surgery versus surgery + radiotherapy		0.05
	Surgery versus surgery + radiotherapy + chemotherapy		0.04
	Surgery + radiotherapy versus Surgery + radiotherapy + chemotherapy		0.27

Author	Type of study	Number of patients	Mean survival (months)	P-value
Le Prise et al.1994⁽¹²⁾	Randomized	41 (chemo) vs 45	11	0.56
Le Prise et al.1994⁽¹²⁾	Randomized	(surgery)	11	0.56
Bosset et al.1994⁽³⁾	Randomized	143 (chemo) vs	18.6	0.78
Bosset et al.1994⁽³⁾	Randomized	139 (surgery)	18.6	0.78
Ancona et al.2001⁽²⁾	Randomized	47 (chemo) vs	25	0.01
Ancona et al.2001⁽²⁾	Randomized	47 (surgery)	24	(only complete pathological response)
Urba et al.2001⁽²⁵⁾	Randomized	50 (chemo) vs	17.6	0.15
Urba et al.2001⁽²⁵⁾	Randomized	50 (surgery)	16.9	0.15
El Nakadi et al.2001⁽⁸⁾	Non-randomized	38 (surgery) vs	Unavailable	0.19
El Nakadi et al.2001⁽⁸⁾	Non-randomized	61 (radio + chemo)	21	0.19
Urschel et al.2002⁽²⁶⁾	Meta-analysis of nine	1116 (total)	Odds ratio:	0.016
	randomized studies	surgery vs	0.79 (1st year)	(3rd year)
		(radio + chemo)	0.77 (2nd year)
		(radio + chemo)	0.66 (3rd year)
Makary et al.2003⁽¹⁴⁾	Non-randomized	76 (surgery) vs	17.2 vs	0.01
Makary et al.2003⁽¹⁴⁾	Non-randomized	40 (radio + chemo)	35.7	0.01
Liao et al.2004⁽¹³⁾	Non-randomized	72 (surgical) vs	12 vs	<0.05
Liao et al.2004⁽¹³⁾	Non-randomized	60 (radio + chemo)	62	<0.05
Malaisrie et al.2004⁽¹⁵⁾	Non-randomized	65 (surgical) vs	28.7 vs	0.14
Malaisrie et al.2004⁽¹⁵⁾	Non-randomized	31 (radio + chemo)	24.1	0.14
Fiorica et al.2004⁽⁹⁾	Meta analysis of six	390 (surgery) vs	Odds ratio:	0.03
Fiorica et al.2004⁽⁹⁾	randomized studies	388 (radio + chemo)	0.53 (3rd year)	(3rd year)
Greer et al.2005⁽¹⁰⁾	Meta-analysis	364 (surgery) vs	Odds ratio:	0.74
Greer et al.2005⁽¹⁰⁾	(6 randomized studies)	374 (radio + chemo)	0.86	0.74
Zhang et al.2005⁽²⁹⁾	Non-randomized	59 (surgery) vs	19.3% (4 years) vs	<0.05
Zhang et al.2005⁽²⁹⁾	Non-randomized	56 (radio + chemo)	33.3% (4 years)	<0.05
Morgan et al.2007⁽¹⁸⁾	Non-randomized	117 (chemo) vs	24 vs	0.03
Morgan et al.2007⁽¹⁸⁾	Non-randomized	88 (radio + chemo)	43	0.03
Andreollo et al.2012	Non-randomized	23 (surgery) vs	32.4	0.05
		71 (radio) vs	65.4
		16 (radio + chemo)	87.2

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