The latest research conducted by a team from University of Texas MD Anderson Cancer Center identified that chemoradiation prior to surgery offsets the quality of results in patients with adenocarcinoma. Dr. Jaffer Ajani and his colleagues at MD Anderson discovered that trimodality therapy (with surgical management) that is preceded by chemoradiation renders “unimpressive results.”
According to the research, which was recently published in the Journal of Clinical Oncology, 36% of patients who underwent chemoradiotherapy developed distant metastases in association with locoregional failure in some cases. The team also identified that 89% of these cases were reported within 3 years (or 36 months of the surgical treatment of esophageal adenocarcinoma.
Details of the study:
The research team followed 518 subjects (with a known history of esophageal adenocarcinoma) receiving trimodality treatment as part of salvage therapy and frequency of locoregional lesions. In all of the patients, surgical procedures like esophagectomy were performed after chemoradiotherapy and tumor restaging.
– In order to track the metastasis and recurrence of tumors, periodic endoscopic procedures were performed every 6 months for first 18 months, and yearly after that period.
– Patients were called for follow-up visits once every 3 months for the first year, once every 6 months for the second post- operative year, and once a year for next 5 years. During each visit, blood investigations, PET scans, and CT scans were performed.
During the study, the team recorded the metastatic and recurrent tumor lesions. Researchers also monitored the presence or absence of locoregional failure and concurrently excluded the patients who developed both metastatic lesions and locoregional failure (as these patients were not enrolled for salvage therapy).
Salvage therapy initiated in other group with chemotherapy was tightly monitored, and the surgery was used only as a last resort.
Analysis of the study:
The study analysis suggested:
– Median age of study subjects: 61 years
– Duration of median follow-up (starting from the procedures- esophagectomy): 29 months
– 239 patients who remained alive till the completion of study has a median follow- up duration : 55 months
– T3 tumors reported in 79%
– T2 tumors reported in 14%
– T4a tumor is 2% (resectable tumor)
– T1 tumor in 1%
– Stage M1a disease was reported in 5%
– Stage N disease reported in 62%
The esophageal junction was identified as the most common tumor location (in approximately 65% cases) with approximately 2% reported in the mid-esophagus and 33% in the lower esophagus.
Among the 5% study population who developed locoregional failure after treatment, only a small percentage survived for more than 2 years (5 of 12 patients) after undergoing salvage chemotherapy. Among the survivors, 3 developed distant metastasis.
– Distant metastasis was reported in 36% cases (with or without locoregional failure). 63% cases were diagnosed within the initial 2 – year period while towards the end of 3rd year, the percentage rose to 89%
– Isolated Locoregional failure was reported in 5%
The report suggested: “Thus, only 2% of all 518 patients beneﬁtted from surveillance/salvage strategies.”
Ajani and his colleagues explained:
After [trimodality therapy], patients are surveyed by various schedules and tests … the primary reason to survey patients after successful local therapy … is to implement a potentially beneﬁcial salvage therapy to overcome locoregional failure. The purpose of this study was to analyze a large cohort of patients who had [trimodality therapy] and to assess the outcome of patients for whom salvage therapy was implemented following locoregional failure.”
Importance of the research findings:
The results of this study are noteworthy because the conclusion and recommendations contradict prior research in which investigators identified a clear advantage in the 5-year survival rate after pre-surgical chemoradiotherapy, as opposed to patients of advanced esophageal adenocarcinoma who only received chemotherapy. These previous findings were the result of a study conducted by researchers at the University of California, and was presented at the Gastrointestinal Cancers Symposium earlier this year.
In addition, previous research also proved that pre-operative treatment is not helpful in the initial stages of esophageal adenocarcinoma. The research team concluded: “The good news is that the rate of locoregional failure only is remarkable low after trimodality therapy.”
The authors suggested that although periodic surveillance is a workable option in western countries; there are a number of limiting factors like added morbidity, stress and heavy economical cost that limits the potential benefits of surveillance.