Combined Modality Therapy of cT2N0M0 Esophageal Cancer: UT M. D. Anderson Cancer Center Experience

Esophageal carcinoma is an aggressive malignancy and a major cause of cancer–related deaths worldwide.1 The incidence of esophageal adenocarcinoma has been rising faster than that of any other cancer in the western world for several decades2, 3 and in 2009, a total of 16,470 new cases and 14,530 deaths were estimated in the United States.4 Therapy options available to patients with localized ≥cT1b esophageal cancer located in the thoracic cavity include primary surgery, preoperative therapy, or definitive chemoradiation therapy.5 Patients with cT1a cancer are best treated by an endoscopic mucosal resection and cT1bN0 by primary surgery but surgery for cT2-3 N1 or N0 cancer leads to poor survival at 5 years and preoperative therapy is often utilized without unequivocal level 1 evidence.6 Preoperative chemoradiation is preferred in the USA7, 8 and preoperative chemotherapy is less preferred as two randomized trials are essentially negative.9, 10 cT2N0 is a particularly interesting entity and its primary treatment remains a subject of debate. Only limited information is available in the literature.11 Rice et al. made a number of important observations that have implications on potential therapeutic strategies. All their 53 cT2N0M0 patients, who underwent surgery as primary therapy, were staged by computerized tomographic scans and endoscopic ultrasonography, however, only 7 (13%) had ypT2N0M0 and 17 (32%) had a higher yp stage than the clinical stage. The overall 10-year survival of 53 patients was approximately 30%. The authors also reported on 8 patients who had preoperative chemoradiation therapy, they all did poorly. It would appear from this solitary experience that there is considerable stage migration (in both directions) and that the outcome of patients with surgery alone is poor. Nevertheless, surgery as primary therapy for this group of patients is not ruled out. Clearly, cT2N0M0 esophageal cancer is not a common entity and there is no agreement as to how these patients should be treated. Rice et al. recommended surgery first as their preference and postoperative adjuvant therapy if needed. They also emphasized the need for more accurate clinical staging methods. In this manuscript, we present our experience with 49 patients who were fully staged and received preoperative chemoradiation therapy.