title: Preoperative Chemoradiation Therapy Versus Chemotherapy in Patients Undergoing Modified En Bloc Esophagectomy for Locally Advanced Esophageal Adenocarcinoma: Is Radiotherapy Beneficial?
abstract: BACKGROUND
  Preoperative chemotherapy (ChT) or chemoradiation (ChRT) are associated with improved outcomes compared with up-front surgical resection in patients with locally advanced esophageal adenocarcinoma (EAC). Two randomized controlled trials comparing these therapies included nonradical resection and failed to reach significance. We hypothesized that additional regional radiotherapy does not benefit patients undergoing en bloc resection.
  
  
  METHODS
  We performed a multiinstitutional study using three prospectively entered databases from high-volume esophageal centers. Inclusion criteria were patients with EAC treated with preoperative ChT or ChRT, followed by modified en bloc esophagectomy. To minimize issues of stage migration and heterogeneity, we limited the study to patients with cT3 N1 M0 EAC. Survival was assessed by the Kaplan-Meier method, and step-wise multivariable analyses were used to explore variables independently associated with survival outcomes. Radical resections included two- and three-field lymphadenectomies, dependent solely on surgeon/institutional preference.
  
  
  RESULTS
  We identified 214 patients with cT3 N1 disease, of which 114 underwent preoperative ChT vs 100 who underwent ChRT. Median survival was 31.2 months (95% confidence interval, 20.7 to 41.7 months) for the ChT group vs 39.2 months (95% confidence interval, 27.3 to 51.0 months) for the ChRT group (p = 0.665). Mortality at 90 days was 5.3% for ChT vs 4% for ChRT (p = 0.754). No differences were noted between patterns of locoregional and distant recurrence between both groups. There were no significant differences in major postoperative morbidity between both groups.
  
  
  CONCLUSIONS
  Given a modified en bloc esophagectomy, type of preoperative therapy was not a significant determinant of overall survival or disease-free survival. Although preoperative ChRT did not add perioperative risk, it also did not prolong survival. The role of preoperative radiotherapy in the setting of a planned radical resection should be further evaluated.
authors.affiliation: Department of Cardiovascular and Thoracic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas; Division of Thoracic Surgery, McGill University Health Center, Montreal, Quebec, Canada.
authors.forename: Jonathan D
authors.initials: JD
authors.lastname: Spicer
authors.affiliation: Department of Cardiothoracic Surgery, Weil Cornell Medical College, New York, New York.
authors.forename: Brendon M
authors.initials: BM
authors.lastname: Stiles
authors.affiliation: Division of Thoracic Surgery, McGill University Health Center, Montreal, Quebec, Canada.
authors.forename: Monisha
authors.initials: M
authors.lastname: Sudarshan
authors.affiliation: Department of Cardiovascular and Thoracic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Arlene M
authors.initials: AM
authors.lastname: Correa
authors.affiliation: Division of Thoracic Surgery, McGill University Health Center, Montreal, Quebec, Canada.
authors.forename: Lorenzo E
authors.initials: LE
authors.lastname: Ferri
authors.affiliation: Department of Cardiothoracic Surgery, Weil Cornell Medical College, New York, New York.
authors.forename: Nasser K
authors.initials: NK
authors.lastname: Altorki
authors.affiliation: Department of Cardiovascular and Thoracic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas. Electronic address: whofstetter@mdanderson.org.
authors.forename: Wayne L
authors.initials: WL
authors.lastname: Hofstetter
mesh_terms: D000230:Adenocarcinoma / Q000175:diagnosis / Q000628:therapy*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000627:therapeutic use*; D059248:Chemoradiotherapy; D004938:Esophageal Neoplasms / Q000175:diagnosis / Q000628:therapy*; D016629:Esophagectomy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011300:Preoperative Care / Q000379:methods*; D011446:Prospective Studies; D018714:Radiotherapy, Adjuvant; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000970:Antineoplastic Agents