The Growing Pains of Neoadjuvant Trials for Gastroesophageal Carcinoma

Excerpt

In this issue of the Annals of Surgical Oncology, Gaca et al.1 from Duke University Medical Center present a retrospective analysis of 101 patients receiving neoadjuvant chemoradiation followed by surgical resection for gastroesophageal junction (GEJ) carcinoma. The purpose of the study was to identify factors affecting the overall survival and disease-free survival (DFS) in patients receiving multimodality therapy for GEJ tumors. Almost 90% of the tumors were located in the distal esophagus, and all but five were adenocarcinoma. All patients underwent pretreatment staging with computed tomographic scanning of the chest and abdomen, and endoscopic ultrasonography (EUS) was performed in 39 patients. The predominant chemotherapy regimen consisted of continuous-infusion 5-fluorouracil (225 mg/m²) and cisplatinum (20 mg/m²) for three cycles. Radiation therapy began the first day of chemotherapy and was delivered to a total dose of 45 Gy. Surgical resection was performed 4 to 8 weeks after completion of neoadjuvant chemoradiation. The median overall survival was 25 months, and the median DFS was 16 months. A pathologic complete response (pCR) was achieved in 28 patients (27%) with a median survival of 50 months. Patients with node-negative tumors experienced a median DFS of 24 months compared with 9 months for patients with node-positive tumors. Pathologic N status was the only variable found to be statistically significant by both univariate and multivariate analysis. The authors concluded from their study that the identification of lymph node metastases in patients with GEJ/esophageal tumors receiving neoadjuvant therapy followed by resection portends a poor prognosis. They also suggest that patients enrolled in neoadjuvant protocols undergo posttreatment nodal restaging and that consideration be given to curtailing or modifying future surgical management if positive lymph nodes are detected. …