Last modified: 2022-09-21
Abstract
Background:Neoadjuvant chemoradiotherapy (NACRT) using CROSS protocol has improved the oncological outcomes of oesophageal cancer. The real-world experience of CROSS regimen for oesophageal squamous cell carcinoma (OSCC), with regards to its feasibility, safety and factors predicting treatment completion is sparsely reported.
Methodology:A retrospective review of patients with OSCC receiving CROSS protocol (RT-41.4Gy) or a modified CROSS protocol (RT-45Gy) between 2016 and 2022. The treatment tolerability, factors predicting NACRT completion, and the effect of its completion on the pathological outcomes were studied.
Results:Of the109 patients (Male,68.8%;mean age,56±9 years;19.3% with Charlson comorbidity index (CCI)>2;58% stage III or IVA, mean tumor length,5.5±2.1cm) included, all except four patients completed radiotherapy but ≥4 chemotherapy cycles were completed by only 58 (53.2%) patients. The commonest reason for non-completion of chemotherapy was the occurrence of neutropenia (60.9%). Forty-nine patients (45%) would have been ineligible for NACRT, if the CROSS trial inclusion criteria were applied. Twenty six patients (23.9%) did not receive surgery; the commonest reasons being patient refusal and disease progression (7.3% each). All patients received McKeown’s oesophagectomy (minimally invasive,91.4%); the major postoperative morbidity was 23.1%, the median postoperative stay was 10 days, and there was no mortality. Pre-treatment anemia (hemoglobin<12vs.≥12gm/dL; p=0.03), a high CCI (>2vs.≤2;p=0.047) and conventional radiation techniques (conventional vs. conformal;p=0.028) were independently associated with non-completion of chemotherapy (<4cycles). Although there was a trend towards improved R0 resection (95.7%vs.91.4%), reduced node positivity (17.0%vs.31.4%) and high pCR (57.4%vs.48.6%) in patients completing chemotherapy (≥4cycles) vs. those who didn’t (<4cycles), these differences were statistically non-significant.
Conclusion:Patients with OSCC receiving NACRT as per CROSS protocol or a modified protocol often exhibit poor chemotherapy tolerance. Neutropenia is a major factor limiting chemotherapy delivery but anaemia, high CCI, and application of conventional radiation techniques are also associated with non-completion of therapy. Completion of chemotherapy has no significant effect on the pathological outcomes.