Clinical analysis of the surgical indication after neoadjuvant chemoradiotherapy for the advanced esophageal cancer

Chemoradiotherapy (CRT) has been widely used for advanced esophageal cancer patients to improve their prognosis. There were some cases in which we could not be sure that neoadjuvant CRT should be followed by surgery. Therefore, to define the indication of surgery, we evaluated the risk of surgery after CRT and also determined the significant prognostic factors in patients after such surgery. Esophageal cancer patients who were treated in our department since 1989 were classified into two groups 28 patients who underwent surgery following neoadjuvant CRT (CRT-op group) and 194 patients who underwent surgery without any previous treatment (control-op group). The surgical stress, immunocompetence, incidence of postoperative complications and hospital death, and duration of hospital stay were compared between the CRT-op group and the control-op group. The significant prognostic factors were analyzed in the CRT-op group. The CRT-op group included significantly more patients with upper thoracic esophageal cancer and also patients who underwent three-field lymph node dissection compared with the control-op group. The mean operating time and blood loss were significantly more in the CRT-op group. Total lymphocyte counts were significantly lower by postoperative day (POD) 9 in the CRT-op group than in the control-op group. The CRT-op group also showed significantly lower immunological function assessed with lymphocyte transformation test on the POD 1 compared with the control-op group. Although anastomotic leakage and hospital death were observed more frequently in the CRT-op group than in the control-op group, there was no significant difference in the incidence of operation-related death and the duration of postoperative hospital stay. It was characteristic of the CRT-op group that the independent prognostic factors were revealed to be surgical curability and histological depth of tumor. Surgery following CRT appeared to be safe despite of the increased surgical stress and damaged immunological competence. Because the hospital death due to regrowth of the tumor occurred more frequently in the CRT-op group, surgery following neoadjuvant CRT must be indicated in the patients for whom the surgical procedure will be completely curative. (author)