Preoperative chemoradiotherapy and surgery for oesophageal cancer

Review of short term safety and efficacy results.

The optimal neoadjuvant (NA) regime for cancers of the oesophagus and OGJ remains controversial. In the UK preoperative chemotherapy is the standard of care and we have been slow to adopt chemoradiotherapy (CRT) fearing increased surgical morbidity and under-treatment of systemic disease. The CROSS trial showed improved survival for patients treated with chemoradiotherapy (CRT) and surgery compared to surgery alone and has led to a renewed interest in the use of CRT in the UK.

The standard: 

The CROSS trial showed a satisfactory safety profile for neoadjuvant chemoradiotherapy followed by surgery, a 29% complete pathological response rate, 92% R0 resection rate and improved 3 year survival rates.

Target: 

To compare local safety and efficacy results with the results of the CROSS trial.

Indicators: 

1. Percentage >=G3 chemoradiotherapy toxicities

2. Percentage surgical morbidity and mortality

3. Percentage pathological response rate

4. Percentage R0 resection rate

Data items to be collected: 

1. Grade 3-5 chemoradiotherapy toxicities

2. Perioperative complications and postoperative mortality

3. Pathological response rate and resection margins

Suggested number: 

At least 25 consecutive patients treated with preoperative chemoradiation for oesophageal cancer.

1. To discuss the results of the audit at the upper GI MDT meeting

2. To develop local practice protocols for the use of neoadjuvant chemoradiation

3. To continue a prospective audit of neoadjuvant chemoradiation and surgery and a long term follow up data analysis

- Electronic patient records

- Radiology imaging (EUS, CT, PET) reports

- Histopathology reports

1. Van Hagen et al. Preoperative Chemoradiotherapy for Esophageal or Junctional Cancer. NEJM 2012; 366:2074-2084

2. Mariette et al. Surgery alone versus chemoradiotherapy followed by surgery for stage I and II esophageal cancer: Final analysis of randomized controlled phase III trial FFCD 9901. J Clin Oncol 2014; 32:2416-2422

3. Tepper et al. Phase III Trial of Trimodality Therapy With Cisplatin, Fluorouracil, Radiotherapy, and Surgery Compared With Surgery Alone for Esophageal Cancer: CALGB 9781. J Clin Oncol 2008; 26:1086-1092

4. Sjoquist et al. Survival after neoadjuvant chemotherapy or chemoradiotherapy for resectable oesophageal carcinoma: an updated meta-analysis. Lancet Oncol 2011; 12:681-692

5. Vellayappan BA et al. Chemoradiotherapy versus chemoradiotherapy plus surgery for esophageal cancer. Cochrane review 2013

6. Kumagai et al. Meta-analysis of postoperative morbidity and perioperative mortality in patients receiving neoadjuvant chemotherapy or chemoradiotherapy for resectable oesophageal and gastro-oesophageal junctional cancers. Br J Surg 2014Mar; 101(4):321-328

Jan Ponichtera

Co-authors

F. Noble

D. Sharland

J. Byrne

J. Kelly

A. Jackson

T. Underwood

A. Bateman