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Combining neoadjuvant chemoradiation with adjuvant chemotherapy in multimodality treatment for patients with potentially curable esophageal carcinoma.

e15574 Background: Optimal multimodality treatment followed by surgical resection results in cure for less than half of patients with operable adenocarcinoma of the lower esophagus or GEJ. The current standard of care is either neoadjuvant chemoradiation established by the CROSS trial or perioperative chemotherapy established by MAGIC trial. We aimed to investigate whether additional treatment beyond current standards of care might improve outcomes. Methods: We performed a phase II, single center, investigator initiated study assessing the combination of neoadjuvant chemoradiation followed by esophagectomy and adjuvant chemotherapy in patients with resected esophageal/GEJ cancer. All patients received neoadjuvant infusional 5-fluorouracil at 225mg/m2 for 5 days with concurrent radiation at a dose of 4500 cGy followed by esophagectomy and 6 cycles of adjuvant paclitaxel 200mg/m2 on day 1, carboplatin AUC 6 on day 1 and infusion 5-fluorouricil 225 mg/m2 on days 1-7 (PCF) on a 28-day cycle. Results: 27 patients with stage IIA-IIIB (AJCC7) esophageal/GEJ tumors were enrolled on the protocol between 1999 and 2007. There were 23 males and 4 females with a median age at diagnosis 58 years. Twenty-five patients had adenocarcinoma, 1 had squamous and 1 had adenosquamous histology with 14 tumors located in GEJ and 11 in lower 1/3 of esophagus. The time between the surgery to start of PCF was 2.4 months. Fifteen patients (55.6%) had an R0 resection margin at the time of surgery. Only 8 (30%) patients could complete all 6 cycles of planned adjuvant chemotherapy, median number of cycles of chemotherapy administered was 1. Patients were followed for 10 years. Median progression free and overall survival was estimated to be 11.9 and 18.8 months respectively. At present time only one patient is alive and free of disease. One patient passed from an unrelated malignancy. Conclusions: Inferior survival results in this small study may be attributed to difficulty delivering adjuvant chemotherapy after prior chemoradiation, extensive surgery and delayed recovery. Total neoadjuvant therapy may overcome these obstacles in management of esophageal/GEJ cancer patients and should be explored in future studies.