Induction therapy for clinical T4 oesophageal carcinoma; a plea for continued surgical exploration

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Abstract
OBJECTIVE: Complete resection of a locally advanced oesophagealcarcinoma is not always feasible when invading mediastinal structures. Theuse of induction therapy prior to surgical exploration in patients withthese clinical T4 tumours is anticipated to improve the resectability rate.METHODS: Patients, 18, who presented with a carcinoma of the thoracicoesophagus with clinical invasion into the carina (n = 6), trachea (n = 5),aorta (n = 4), lung (n = 2) and diaphragm (n = 1) were treated withconcurrent chemotherapy and radiotherapy followed by surgical exploration.Follow-up was complete (mean of 17 +/- 3 months in all patients and 27 +/-2 months in surviving patients). RESULTS: All patients completed theinduction therapy with acceptable toxicity and no mortality. Subjectiveimprovement in dysphagia was substantial in 11 patients (in 8/11 patients(73%) however, there was still viable tumour in the resected specimen), itwas minimal in six patients and absent in one patient. Objective responseon imaging was complete in one patient, partial in eight patients andminimal in nine patients [in two of these nine patients (22%) nevertheless,the primary tumour had disappeared completely in the resected specimen(pT0)]. Resection was complete (R0) in 14 patients (78%) and incomplete(R1) in one patient (5%). Resection of the primary tumour was impossible(R2) in three patients (17%) because of macroscopic airway (n = 2) andhilar (n = 1) invasion on exploration. In these three patients the tumourwas bypassed using a retrosternal split stomach. One patient was proven atthe time of surgery to have a previously unidentified lung metastasis. Inthree patients (17%), no residual tumour cells were found in the resectedoesophagus nor in the lymph nodes (pT0N0M0). There have been no in-hospital deaths. Actuarial 3 year survival was 43% in all patients, 55% incompletely resected patients and 100% in sterilized patients (pT0N0M0).Median survival was 18 months in all patients. CONCLUSIONS:Chemo/radiotherapy followed by surgery in patients with a clinical T4oesophageal carcinoma is feasible with acceptable toxicity and notreatment-related mortality. Operability and resectability rate were high(100 and 83%, respectively) compared with historical controls. The primarytumour disappeared completely (pT0N0-1M0-1) in 28%. Tumour sterilizationrate was 17%. Survival looks promising compared with historical controls.Subjective neither objective response following induction therapy clearlycorrelated with the final pTNM staging. This indicates that, in the absenceof tumour progression, neither the patient nor the treating physicianshould jeopardize the chance for ultimate cure by denying surgicalexploration following induction therapy.

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