The role of neoadjuvant therapy in surgically resectable esophageal cancer

Objective: To determine the effect of neoadjuvant therapy (NT) (preoperative chemotherapy, radiation therapy, or both) in surgically resectable esophageal cancer. Design: A retrospective review over a 20-year period. Setting: A tertiary academic medical center. Participants: All patients undergoing surgical resection for esophageal cancer (N=316) over this time period. Main Outcome Measures: Perioperative morbidity and mortality, local and distant recurrences, and overall survival. Results: Patients undergoing NT (n = 106) had prognostic factors similar to those treated with surgery alone (n=210). No increase was noted in surgical morbidity with NT (anastomotic leaks, reoperation rates, complications, or extended hospital stays). Overall survival was not improved by NT (median survival, 14 months) except in the subset of patients (11/83) who responded completely (100% histological necrosis) to preoperative chemotherapy (median survival, 79.2 months; P<.02). Complete response to radiation therapy alone was not associated with improved survival. Partial necrosis of the primary tumor was seen in 13 (15%) of 83 patients but conferred no survival advantage. Complete response to preoperative chemotherapy was associated with squamous cell pathological features and excellent performance status as measured by preanesthesia evaluation. Conclusions: The addition of NT did not increase perioperative morbidity or mortality. Only the subset of patients who had a complete response to preoperative chemotherapy showed a survival advantage. Excellent performance status and squamous cell pathological features were associated with an increased chance of complete pathological response following preoperative chemotherapy.