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

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Abstract
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. J. Surg. Oncol. 2005;90:209–219.