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

Complete resection of a locally advanced oesophageal carcinoma is not always feasible when invading mediastinal structures. The use of induction therapy prior to surgical exploration in patients with these clinical T4 tumours is anticipated to improve the resectability rate.

Patients, 18, who presented with a carcinoma of the thoracic oesophagus with clinical invasion into the carina (n = 6), trachea (n = 5), aorta (n = 4), lung (n = 2) and diaphragm (n = 1) were treated with concurrent 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).

All patients completed the induction therapy with acceptable toxicity and no mortality. Subjective improvement in dysphagia was substantial in 11 patients (in 8/11 patients (73%) however, there was still viable tumour in the resected specimen), it was minimal in six patients and absent in one patient. Objective response on imaging was complete in one patient, partial in eight patients and minimal 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) and hilar (n = 1) invasion on exploration. In these three patients the tumour was bypassed using a retrosternal split stomach. One patient was proven at the time of surgery to have a previously unidentified lung metastasis. In three patients (17%), no residual tumour cells were found in the resected oesophagus nor in the lymph nodes (pT0N0M0). There have been no in-hospital deaths. Actuarial 3 year survival was 43% in all patients, 55% in completely resected patients and 100% in sterilized patients (pT0N0M0). Median survival was 18 months in all patients.

Chemo/radiotherapy followed by surgery in patients with a clinical T4 oesophageal carcinoma is feasible with acceptable toxicity and no treatment-related mortality. Operability and resectability rate were high (100 and 83%, respectively) compared with historical controls. The primary tumour disappeared completely (pT0N0-1M0-1) in 28%. Tumour sterilization rate was 17%. Survival looks promising compared with historical controls. Subjective neither objective response following induction therapy clearly correlated with the final pTNM staging. This indicates that, in the absence of tumour progression, neither the patient nor the treating physician should jeopardize the chance for ultimate cure by denying surgical exploration following induction therapy.