title: A retrospective analysis of locally advanced esophageal cancer patients treated with neoadjuvant chemoradiation therapy followed by surgery or surgery alone.
abstract: BACKGROUND
  We conducted an institutional review of patients with locally advanced esophageal cancer who had complete pretreatment and surgical staging to identify variables predictive of outcome.
  
  
  METHODS
  From 1993 through 2002, 286 patients presented for surgical therapy of esophageal cancer. Of these, 176 patients met criteria for review including pretreatment endoscopic ultrasound stages IIA through IVA and a transthoracic surgical approach with "two-field" lymph node dissection. This cohort was primarily male (84.7%, n = 149) with adenocarcinoma (88.6%, n = 156), and 101 patients (57.3%) demonstrated endoscopic ultrasound stage III or IVA.
  
  
  RESULTS
  Eighty-five (48.3%) patients presented to surgery after receiving neoadjuvant chemoradiation therapy, and 91 (51.7%) underwent surgery alone. Both groups were well matched with respect to comorbidities and pretreatment stage. Patients receiving neoadjuvant chemoradiation demonstrated a nonsignificant trend toward increased operative mortality and nonfatal morbidity. The overall median survival was 16.8 months, and there was no survival difference comparing patients treated with neoadjuvant chemoradiation followed by surgery or surgery alone (p = 0.82). The subset of 25 patients (29.4%) demonstrating a complete pathologic response after neoadjuvant chemoradiation therapy however had superior survival (median survival = 57.6 months, p < 0.01) as compared with neoadjuvant chemoradiation patients demonstrating partial downstaging (n = 36, 42.3%), no downstaging (n = 24, 28.2%), and surgery alone patients. Multivariate analysis identified a complete pathologic response, endoscopic ultrasound stage, and number of pathologically positive lymph nodes as independent predictors of survival.
  
  
  CONCLUSIONS
  These data support the use of neoadjuvant chemoradiation for locally advanced esophageal cancer as the subset of patients who demonstrate a complete pathologic response experienced significantly better survival.
authors.affiliation: Department of Surgery, Thoracic Division, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA. kkesler@iupui.edu
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Kesler
authors.forename: Paul R
authors.initials: PR
authors.lastname: Helft
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Werner
authors.forename: Neel P
authors.initials: NP
authors.lastname: Jain
authors.forename: Jo Ann
authors.initials: JA
authors.lastname: Brooks
authors.forename: John M
authors.initials: JM
authors.lastname: DeWitt
authors.forename: Julia K
authors.initials: JK
authors.lastname: Leblanc
authors.forename: Naomi S
authors.initials: NS
authors.lastname: Fineberg
authors.forename: Lawrence H
authors.initials: LH
authors.lastname: Einhorn
authors.forename: John W
authors.initials: JW
authors.lastname: Brown
mesh_terms: D000328:Adult; D000368:Aged; D017024:Chemotherapy, Adjuvant; D004938:Esophageal Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D020360:Neoadjuvant Therapy; D009367:Neoplasm Staging; D018714:Radiotherapy, Adjuvant; D012189:Retrospective Studies