Multimodality treatment for esophageal malignancy: the roles of surgery and neoadjuvant therapy

The best curative treatment for esophageal malignancy remains controversial. In 2003, we presented our institution's experience with 124 patients treated from 1990 to 2001. Here we update that experience with an additional 6 years' data. A total of 221 patients underwent surgical resection from 1990 to 2007; 128 had up-front surgery, 88 underwent surgery after neoadjuvant radiation and chemotherapy (NARCS), and five underwent surgery after neoadjuvant, single-agent therapy. Principle outcomes of interest were 30-day and in-hospital mortality as well 3- and 5-year survival rates. Overall 3- and 5-year survival rates were 38 and 33 per cent. NARCS achieved complete pathologic result in 32 per cent of patients with corresponding 3- and 5-year survival rates of 58 and 53 per cent. The 3- and 5-year survival rates for all patients undergoing NARCS were 36 and 31 per cent versus 24 and 18 per cent for patients with up-front surgery for anything over Stage I disease (P = 0.01). The 3- and 5-year survival rates for patients with up-front resection of Stage I disease were 78 and 70 per cent. Overall, 30-day and in-hospital mortalities were 1.8 and 2.3 per cent. Since January 1, 2000, hospital mortality has been less than 0.8 per cent. We prefer NARCS for malignancy of the esophagus, except in those patients with high-grade dysplasia (carcinoma in situ), suspected Stage I disease, poor performance status, or urgent/emergent circumstances.