This document summarizes a study comparing outcomes of patients who underwent upfront surgery versus neoadjuvant therapy followed by surgery for esophageal cancer. The study analyzed 49 patients treated between 2015-2019 at a hospital in India. It found no significant differences in patient characteristics or postoperative complications between the two groups. However, the neoadjuvant therapy group had a higher rate of pathological complete response (20% vs 0%) and lower rate of adjuvant chemotherapy (41% vs 68%). After a median follow-up of 28 months, there was no significant difference in survival time or rates between the two groups. The study concludes that neoadjuvant therapy prior to surgery is a feasible approach and can achieve higher rates of pathological complete response

1. Presenter: Dr. Rajesh Mopuri
2nd Year PGT,
Department of General Surgery
Gauhati Medical College and Hospital
Moderator: Dr. Kabir Rajkhowa
Professor
Dept. of General Surgery,
GMCH
M. P. Viswanathan1 & D. Suresh Kumar1 & G. Arul Kumar1 & J. Sakthi Usha Devi1 & T. D.
Balamurugan1
Analysis of Carcinoma of the Esophagus Patients
Between Upfront Surgery vs. Neoadjuvant
Therapy Followed by Surgery

2. AIM
 The aim is to carry out a retrospective analysis of carcinoma of the esophagus
patients who underwent upfront radical esophagectomy (RE) versus neoadjuvant
therapy (NAT) followed by radical esophagectomy.

3. Introduction
 Esophageal cancer is the eighth most common cancer worldwide .
 In India, it is the sixth most common cancer and a common cause of cancer-related
mortality .
 The treatment outcomes are poor with 5-year survival ranging from 20 to 35%.
 The management is still evolving. Improvement in survival with neoadjuvant
chemoradiotherapy (NACRT) followed by surgery has been analyzed in various
studies.
 The Gebski meta-analysis demonstrated the superiority of NACRT over surgery
alone (HR 0.78 (95% CI 0.70–0.88; p<0.0001)[7, 8]. However, it has not become the
standard

4. of care in many centers due to fear of perioperative morbidity and lack of
infrastructure.

5. Methods
 This study was conducted by a single surgical team in the Dept of Surgical Oncology,Tamil Nadu
Government Multi Super Speciality Hospital (TNGMSSH), Madras Medical College, Chennai, South
India. during the period 2015 to 2019
 It is a retrospective comparative study of patients undergoing upfront radical esophagectomy
(group A) versus patients undergoing surgery after neoadjuvant therapy (group B)
 A total of 55 cases were recorded.
 Six patients were lost to follow-up.
 Among the remaining 49 patients, 24 received neoadjuvant therapy and 25 underwent upfront
surgery.
 Except the patients who were lost to follow-up, for all other patients, different variables were
analyzed, including patient age, sex, and presence or absence of comorbidities; various tumor
characteristics including tumor location, site, histology, grade, length of lesion, and clinical stage
based on imaging were compared.

6. • Treatment variables studied included pre-op treatment methods, type of surgery
(transhiatal esophagectomy (THE), video-assisted thoracoscopic surgery (VATS) also
called hybrid minimally invasive esophagectomy (HMIE)), duration of surgery, blood
transfused, number of days of hospital stay, and anastomotic leak and were compared .
• Pathologic characters of postoperative histopathology specimen like histology, grade,
margin, node, and pathologic complete response were compared .
• After a median follow-up of 28 months, survival status including time of death, cause of
death, and survival period were analyzed statistically .

7. STATISTICAL ANALYSIS
 Statistical analysis was carried out using SPSS version 17.
 Outcomes were compared using the chi-squared test, and p value of <0.005 was
considered statistically significant.
 Overall survival was calculated using the Kaplan-Meier curve.

8. RESULTS
 Patient variables:
 A total of 55 cases were recorded in the study period.
 Six patients were lost to follow-up.
 Comparison of patient characteristics in group A and group B did not reveal any statistically significant
difference in patient age, sex, location of disease, site of lesion, and comorbidities.
 The location of lesion was commonlyinthe esophagus. Seven cases were OG junction lesion in group A
and 2 cases in group B.
 The site of lesion was most commonly in the lower esophagus and the OG junction in group A. It was
most commonly in the mid esophagus and the lower esophagus in group B.
 Adenocarcinoma(AC) was common in groupA vs. squamous cell carcinoma (SCC) (15:10). Squamous
cell carcinoma was predominant than adenocarcinoma in group B (21:3).
 The predominant symptom of presentation was dysphagia to solids on either group. The
comorbidities were similar statistically in both groups.

10.  Treatment Variables:
 Based on imaging with CECT of the chest, patients with early resectable lesions like T1, T2,
T2, and N0 are generally subjected to upfront surgery (group A) whereas those with T3,
T4, and N+ disease were subjected to NAT (group B).
 Among 29 cases of group A, four lost to follow-up. In the remaining 25, one was
inoperable, 12 underwent transhiatal esophagectomy (THE), and 12 underwent VATS
esophagectomy.
 Among 26 patients who underwent neoadjuvant therapy, two lost to follow-up.
Amongtheremaining 24, the predominant neoadjuvant therapy was neoadjuvant
chemoradiotherapy (NACRT).
 The commonly used NACRT regimen was radiotherapy of 41.4Gy with weekly cisplatin.On
the following with surgery, 17 were operable and seven were inoperable. Twelve
underwent VATS, three underwent THE, and two got converted from VATS to THE.
 The duration of surgery and number of days of hospital stay were similar in either group.
The perioperative event like pulmonarycomplications and anastomotic leak were
statistical-ly insignificantbetweenbothgroups.

12.  PathologicalVariables :
 On histopathologic assessment of postoperative specimen ,the mean nodal harvest was 16 in
groupA and 12 in groupB.
 In groupA, 8patients (32%) and in groupB, 14 patients (58.3%) were pathologic N0. Five patients
(20% ) receiving NAT showed a pathological complete response (pCR-T0N0) to neoadjuvant
therapy. Assessment of histopathological mar-gins suggested R0 resection in both groups. Based
on postoperative histopathology, 17 patients (68%) received adjuvant chemo in groupA and ten
patients (41%) in groupB. The higher rate of pathologic complete response (pCR) in groupB (20%)
was evident and they were not exposed to further chemotherapy. The inoperable patients re-
ceived palliative chemotherapy.

14.  SurvivalAnalysis :
 After a median follow-up of 28months, survival status was analyzed statistically.Seventy-two percent
percent were alive in groupA and 50% in groupB. But it was not statistically significant. The
predominant cause of death was dysphagia-induced mal-nutrition and cachexia. One case had
hematemesis leading onto death. The mean survival for groupA is 10.9±8. 9months and for groupB,
it is12.8±10.8. There was no statistical significance in survival between the groups (pval-ue=0.503).
The KKaplan-Meiercurve for both groups shows higher mortality rate within the first 12 months
follow-ed by a plateau. The survival curve for groupA is higher than that for groupB but not
statistically significant.

17. DISCUSSION
 The objective of neoadjuvant therapy is to increase survival by possibly treating
micrometastasis and achieving better disease control.
 In a study by Bosset et al., there was improvement in disease-free survival with
neoadjuvant therapy in stages I and II but low overall survival (OS) due to increase
in post-operative mortality.
 Advances in patient selection and perioperative and post operative care have
changed this scenario which was proved by CROSS trial by Shapiro et al., after a
median follow-up of 84.1 months, the median overall survival was 48.6 months
(95% CI 32.1–65.1) in the neoadjuvant chemoradiotherapy plus surgery group and
24.0 months (14.2–33.7) in the surgery-alone group .

18.  But in this study the mean duration of survival is not statistically significant Which may be
due to poor nutritional status of patient and Late stage of presentation
 The pathological complete Response was significantly high following Neoadjuvant therapy

19. CONCLUSION
 Radical esophagectomy after neoadjuvant therapy is a feasible and safer oncologic
procedure.
 Careful case selection and surgical expertise are important determinants in
perioperative outcomes.
 Neoadjuvant therapy has advantage of higher rate of pathological complete
response.

20. THANK YOU