NEOADJUVANT CONCURRENT CHEMORADIOTHERAPY IN PATIENTS OF ESOPHAGUS AND GASTROESOPHAGEAL JUNCTION CANCER (SINGLE INSTITUTE STUDY)

Abstract

Background: Esophageal cancer and cancers of the gastroesophageal junction pose significant clinical challenges due to their aggressive nature and often late-stage diagnosis. Neoadjuvant concurrent chemoradiotherapy (CRT) has emerged as a pivotal therapeutic strategy in the management of locally advanced disease. By combining chemotherapy with radiation therapy before surgical intervention, neoadjuvant CRT aims to reduce tumor burden, increase resectability rates, addresses micro metastasis and improve overall survival outcomes.

Objectives: To evaluate pathological response after administering neoadjuvant chemoradiotherapy in patients diagnosed with esophageal cancer and cancers located at the gastroesophageal junction (Squamous cell carcinoma and Adenocarcinoma).

Materials and Methods:  In this prospective interventional study, we enrolled a total of 36 patients, with a diagnosis of esophageal carcinoma or carcinoma of the gastroesophageal junction aged 18-70 years. The study duration was 6 month from (July 2023 to Jan 2024) and was conducted in Department of Radiation Oncology, National University of Medical Sciences (NUMS) Tertiary care Hospital Rawalpindi.  During neoadjuvant chemoradiotherapy, patients received intravenous weekly carboplatin (AUC 2 mg/mL per min) and paclitaxel (50 mg/m²) starting on days 1, 8, 15, 22, and 29. Concurrently, radiation therapy was administered with a total dose of 41.4 Gy delivered in 23 fractions of 1.8 Gy per fraction over 5 days per week (excluding weekends).The entire neoadjuvant treatment spanned at 31 days, with treatment sessions held 5 days per week for the initial four weeks, and then reduced to 3 days in the fifth week. Then all the patients underwent surgery within 12 weeks of completion of the chemoradiation. At follow up we documented pathological responses as  ypTx and ypNx cateogories as per American Joint Committee on Cancer (AJCC) 8th Edition.Histological regression as compelete response, partial response and No response and types of resection as R0: no residual tumor, R1: microscopic residual tumor and R2: macroscopic residual tumor. A predesign questionere was used to collect data.

Results: The mean age of all 36 patients was 55.22±8.95 years. Clinical Stage as per AJCC 8th Edition showed no cT0 patients, 1 (2.8%) as cT1, 8 (22.2%) as cT2, 23 (63.9%) as cT3, and 4 (11.1%) as cT4; cN categories were 10 (27.8%) as cN0, 15 (41.7%) as cN1, 11 (30.6%) as cN2, and none as cN3. Gender distribution included 22 males (61.1%) and 14 females (38.9%). Age groups were 2 (5.6%) aged 18-40, 8 (22.2%) aged 41-50, 18 (50.0%) aged 51-60, and 8 (22.2%) over 60. Histological types were 10 (27.8%) adenocarcinoma and 26 (72.2%) squamous cell carcinoma. Pathological responses were 15 (41.7%) ypT0, 5 (13.9%) ypT1, 7 (19.4%) ypT2, 8 (22.2%) ypT3, and 1 (2.8%) ypT4; ypN categories were 20 (55.6%) ypN0, 8 (22.2%) ypN1, 6 (16.7%) ypN2, and 2 (5.6%) ypN3. Histological regression showed 2 (5.6%) with no response, 17 (47.2%) with partial response, 15 (41.7%) with complete response, and 2 (5.6%) not assessed. Most tumors were esophageal (32, 88.9%) versus gastroesophageal junction (4, 11.1%). Tumor resections revealed that 66.7% were R0 resections, R1 resections accounted for 25.0%. Lastly, 8.3% of the cases were R2 resections. Stratification by gender, age, and histological type showed no significant differences (p-values 0.11, 0.81, and 0.55, respectively).

Conclusion: Neoadjuvant concurrent chemoradiotherapy appears to be an effective treatment strategy for patients with esophageal and GEJ cancer, with promising pathological complete response which is likely to be a predictor of improved overall survival (OS).