Chemoradiotherapy followed by surgery for squamous cell carcinoma of the thoracic esophagus with clinical evidence of adjacent organ invasion

BACKGROUND: The role of surgery for esophageal squamous cell carcinoma (SCC) with clinical evidence of adjacent organ invasion (cT4) is a debated issue. This study was aimed at analyzing our experience with chemoradiotherapy (CRT) followed by surgery as treatment for non-metastatic cT4 SCC of the thoracic esophagus. METHODS: The results of 51 patients consecutively treated at the First Department of General Surgery, University of Verona, from January 1987 to December 2004 were analyzed. RESULTS: The most frequently clinically involved structures were the trachea (43.1%), the main left bronchus (17.6%), and the thoracic aorta (15.7%). CRT was completed in all but one of the patients (98.0%) without toxicity-related deaths. After completion of induction treatment 49 patients underwent surgery (96.1%), and resection was possible in 40 patients (78.4%) but R0 surgery was rarely obtained (39.2%). Pathologic downstaging was achieved in 18 cases (35.3%) while a major response (responders) was observed in 10 patients (19.6%) and a complete response (pT0N0) in 7 (13.7%). The overall median survival time was 11.1 months with a 3-year survival rate of 8.8%. A significantly better survival (P < 0.001) was observed after a R0 resection (median: 22.3 months; 3-year survival: 25.4%; P < 0.001) and for responders (median: 33.1 months; 3-year survival: 25.7%; P = 0.019). CONCLUSIONS: Aggressive multi-modal therapy with CRT followed by surgery in cT4 SCC of the thoracic esophagus is feasible. Surgery should be limited to patients with significant response to induction treatment and a high probability of R0 resection.