Minimal changes.

Top Line: Does neoadjuvant chemo alone reduce morbidity and mortality following minimally-invasive esophagectomy (MIE) compared to neoadjuvant chemoradiation in patients with esophageal squamous cell carcinoma?

The Study: Trials comparing nCT and nCRT have mostly included adenocarcinoma and didn’t use the MIE technique. This Chinese multi-institutional phase 3 trial randomized 264 patients with cT3-4N0-1 esophageal squamous cell carcinoma to either neoadjuvant chemoradiation or chemo alone prior to MIE. Chemoradiation consisted of paclitaxel 50 mg/m2 and cisplatin 25 mg/m2 x 2 delivered concurrent with 2 Gy x 20 = 40 Gy. Chemo alone was paclitaxel 135 mg/m2 and cisplatin 75 mg/m2 x 2 cycles. In both arms, post-op complications occurred in nearly half of patients with a peri-operative mortality rate of roughly 3%. In other words, chemoradiation didn’t increase morbidity or mortality. What’s more, the rate of positive margin resection was excellent at < 3-4% either way. Quite a big difference that emerged, however, was a complete pathologic response rate that was 9x higher after chemoradiation (36%) than after chemo alone (4%). And ypN0 status was achieved in 66% versus 46%, respectively. This translated to diverging overall survival at one year (87% versus 83%, respectively) due to half the number of cancer deaths (7% versus 14%). All of this confirms that the current standard neoadjuvant approach should remain so even in the setting of squamous cell histology and / or minimally-invasive esophagectomy.

TBL: Neoadjuvant chemoradiation remains the best option for locally-advanced esophageal squamous cell carcinoma planned for minimally-invasive esophagectomy as it maximizes tumor control without increasing morbidity. | Wang, JAMA Surg 2021