gms | German Medical Science

Background: To compare moderate-dose radio-chemotherapy (MD-RCT) plus resection versus high-dose radio-chemotherapy (HD-RCT) alone for outcome in locally advanced esophageal cancer patients, and to investigate potential prognostic factors including the pre-radiotherapy (RT) hemoglobin level.

Materials and Methods: A total of 120 patients with uT3-4N1M0 esophageal cancer who were treated either with MD-RCT (45-50.4 Gy) plus resection (n=35) or with HD-RCT (59.4-60 Gy) alone (n=85) were included. The following potential prognostic factors were retrospectively evaluated for survival (OS), metastases-free survival (MFS), and loco-regional control (LC): age (<60 vs. >=60 years), gender, ECOG performance status (1 vs. 2-3), tumor location (upper vs. middle vs. lower third), tumor length (<7 vs. >=7 cm), histology (SCC vs. adeno carcinoma), histologic grade (G1-2 versus G3), hemoglobin level before RT (<12.0 g/dl vs. 12-14 g/dl vs. >14 g/dl), treatment approach (MD-RCT plus resection versus HD-RCT alone), and extent of resection (R0 vs. R1-2). Chemotherapy consisted of 2-3 courses of cisplatin (75 mg/m2 on days 1 + 29 of RT) and 5-FU (1000 mg/m2 on days 1-5 + 29-33 of RT).

Results: On univariate analysis, MD-RCT plus resection resulted in better 2-year-OS (52% vs. 23%, p=0.003), 2-year-MFS (63% vs. 33%, p=0.016), and 2-year-LC (73% vs. 45%, p=0.006) than HD-RCT alone. On multivariate analysis, results maintained significance for LC (p=0.039). Pre-RT hemoglobin was significantly associated with OS (p<0.001), MFS (p=0.013), and LC (p<0.001). Tumor length was significantly associated with OS (p=0.014) and MFS (p=0.006). In the patients receiving surgery, R0-resection was superior to R1-resection with respect to OS (p=0.003), MFS (p=0.003), and LC (p=0.006). MD-RCT plus R0-resection was also superior to HD-RCT alone regarding OS (p<0.001), MFS (p<0.001), and LC (p<0.001). Complications were more frequent in the RCT-plus-surgery group (p<0.001), whereas acute toxicity (p=0.77) and late toxicity (p=0.98) were similar in both groups.

Conclusions: Pre-RT hemoglobin and tumor length were significant predictors for outcome. MD-RCT plus resection resulted in better LC than HD-RCT alone. If R0-resection is possible, MD-RCT plus resection appears preferable, as it results in better outcome. If R0-resection appears unlikely, HD-RCT alone appears preferable regarding the greater morbidity associated with resection.