P-043 - Treatment intensification of neoadjuvant therapy in locally advanced esophageal cancer by addition of 2 cycles of induction chemotherapy prior to ch...

Date 04 July 2015
Event WorldGI 2015
Session Posters
Topics Anti-Cancer Agents & Biologic Therapy
Oesophageal Cancer
Surgery and/or Radiotherapy of Cancer
Presenter S. Saha
Citation Annals of Oncology (2015) 26 (suppl_4): 1-100. 10.1093/annonc/mdv233
Authors S. Saha1, S. Gupta1, S. Sarkar2, A. Ghosh Dastidar3
  • 1Apollo Gleneagles Cancer Hospital, Kolkata/IN
  • 2Kothari Medical Centre, Kolkata/IN
  • 3Institute of Post Graduate Medical Education & Research, Kolkata/IN

Abstract

Introduction

Neoadjuvant treatment prior to surgery in locally-advanced esophageal cancer is rapidly evolving. Preoperative chemoradiation followed by reassessment for surgery is widely practiced, but some centres prefer a couple of cycles of induction chemotherapy prior to preoperative chemoradiation for better resectability– but the issue of increased surgical morbidity is always there. The study aims to explore the impact of pre-surgery treatment intensification by adding neoadjuvant chemotherapy with cisplatin- capecitabine combination prior to concomitant chemoradiotherapy on surgical respectability and to use IMRT as radiotherapy modality to minimize pulmonary toxicity to find any possible benefit in lowering surgical morbidity. Study end points are local control, achievement of operability, surgical morbidity and overall survival.

Methods

This is an ongoing multi-institution prospective study initiated in October 2011 for squamous cell carcinoma esophagus patients with T2 to T4a, N + , M0 disease with ECOG performance score 2 or less and not amenable for radical surgery. Pretreatment metastatic work up included PET CT and endoscopic ultrasound. After informed consent all patients received 2 cycles of upfront chemotherapy with Cisplatin 75 mg/M2 on Days 1 and 22; Capecitabine 1000mg/ M2 from Day 1 to Day 14 and again from Day 22. After 2 cycles of induction chemotherapy patients received Radiotherapy by IMRT (41.4 Gy/ 23 fractions) along with concomitant chemotherapy with cisplatin 30 mg/M2 weekly, capecitabine 625 mg/M2 orally Day 1 to Day 5 for 5 weeks. Meticulous CT-based inverse-planned 9-beam IMRT was done to reduce combined lung V20, mean lung dose and heterogeneity as well as to improve conformity. After completion of chemoradiation patients were reevaluated for resection. If the tumor become resectable, patients underwent surgery, if not, they continued with radiotherapy up to a total dose of 50.4 Gy and then four more chemotherapy cycles exactly same as induction chemotherapy with cisplatin and capecitabine on a three weekly regimen. The operated patients received adjuvant chemotherapy for four cycles of the same regimen.

Results

Result of initial 28 patients with minimum follow up of 18 months is being presented. Treatment compliance was in 100% cases. 18/28 patients were adequately down staged for surgery and resection was done for all of them. Pathological complete response was noted in 8/18 of them. No significant operative morbidity was encountered. Postoperative infection was in none. Remaining 10/28 patients had partial regression but not to that extent to be considered for radical resection. At the end of therapy 8/10 had CR. 1 year OS was recorded in all 18 resected patients and in 7/10 patients who could not be resected. 1-year DFS data was 16/18 and 5/7 respectively.

Conclusion

Addition of 2 cycles of induction chemotherapy prior to chemoradiation resulted satisfactory disease control and enabled radical resection in 65% patients. Patient compliance and treatment response were satisfactory with cisplatin + capecitabine combination - less expensive, less toxic and required less hospital stay. Surgical morbidity was negligible with IMRT as it enabled better conformity and less dose exposure to both lungs compared to 3D CRT. Even patients who remained unresectable enjoyed durable disease control.