Prospective non-randomized trial comparing esophagectomy-followed-by-chemoradiotherapy versus chemoradiotherapy-followed-by-esophagectomy for T4 esophageal cancers

Background and Objectives: Multimodal treatment is commonly adopted for patients with a T4 esophageal cancer. This trial evaluated which therapy offered a better survival: preoperative chemoradiotherapy (CRT) or postoperative CRT. Methods: Forty-three patients with a T4 esophageal cancer were enrolled in a prospective study in which each patient decided for themselves a treatment arm, CRT-followed-by-esophagectomy or esophagectomy-followed-by-CRT. The CRT-followed-by-esophagectomy Group received 36 Gy radiotherapy and simultaneous chemotherapy using cisplatin (CDDP) and 5-fluorouracil (5FU) preoperatively, and then 24 Gy radiotherapy and simultaneous chemotherapy using CDDP and 5FU postoperatively. The esophagectomy-followed-by-CRT Group received 60 Gy radiotherapy with two cycles of simultaneous chemotherapy using CDDP and 5FU postoperatively. Results: Of 26 patients who chose CRT-followed-by-esophagectomy, 15 (58%) underwent esophagectomy, while 7 (27%) refused surgery and 4 (15%) were inoperable. Of 17 patients who chose esophagectomy-followed-by-CRT, 14 (82%) underwent esophagectomy, while 3 (18%) underwent inspection thoracotomy. The CRT-followed-by-esophagectomy Group showed a significantly better 5-year-survival rate than the esophagectomy-followed-by-CRT Group (26% vs. 0%). Multivariate analysis demonstrated that only the response to CRT was prognostic. Conclusions: This trial concluded that the first choice of treatment for patients with a T4 esophageal cancer was prior CRT rather than prior esophagectomy. (c) 2005 Wiley-Liss, Inc.