Chemoradiotherapy, with adjuvant surgery for local control, confers a durable survival advantage in adenocarcinoma and squamous cell carcinoma of the oesophagus
Menée à partir des données de deux essais incluant au total 211 patients atteints d'un carcinome épidermoïde ou d'un adénocarcinome de l'œsophage traité entre 1990 et 1997 (durée de suivi : 206 mois), cette étude montre que l'ajout d'une chimioradiothérapie à un traitement chirurgical permet d'améliorer durablement la survie des patients
Introduction : Oesophageal cancer usually presents with systemic disease, necessitating systemic therapy. Neo-adjuvant chemoradiotherapy improves short-term survival, but its long-term impact is disputed because of limited accrual, treatment-protocol heterogeneity and a short follow-up of randomised trials. Aims : Long-term results of two simultaneous randomised controlled trials (RCTs) comparing neo-adjuvant chemo-radiotherapy and surgery (MMT) with surgical monotherapy were examined, and the response of adenocarcinoma (AC) and squamous cell carcinoma (SCC) to identical regimens compared. Methods : Between 1990 and 1997, two RCTs were undertaken on 211 patients. Patients with AC (n = 113) or SCC (n = 98) were separately-randomised to identical protocols of MMT or surgical monotherapy. Results : 211 patients were followed to 206 months; 104 patients were randomised to MMT (58 AC and 46 SCC, respectively) and 107 to surgery. MMT provided a significant survival-advantage over surgical monotherapy for AC (P = 0.004), SCC (P = 0.01). There was a 54% relative risk-reduction in lymph-node metastasis following MMT, compared with surgery (64% versus 29%, P < 0.001). MMT produced a pathologic complete response (pCR) in 25% and 31% of AC and SCC, respectively. Survival advantage accrued to MMT, pCR and node-negative patients: AC pCR versus surgical monotherapy (P = 0.001); residual disease following MMT versus surgical monotherapy (P = 0.008); SCC pCR versus surgical monotherapy (P = 0.033). Conclusions : A survival advantage for MMT persisted long-term in AC and was replicated in SCC. MMT produced loco-regional tumour down-staging to extinction in 25–31% of patients, potentially permitting personalised treatment in this cohort that avoids the morbidity and mortality associated with resection. Node-negative patients with residual localised disease following MMT had a survival advantage over node-negative patients following surgery alone, supporting a systemic effect on micro-metastatic disease.