Multimodal management of gastroesophageal junction adenocarcinoma; which type of neoadjuvant treatment?


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A Master's thesis.
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Master (thesis) (master)
Multimodal management of gastroesophageal junction adenocarcinoma; which type of neoadjuvant treatment?
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Université de Lausanne, Faculté de biologie et médecine
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Objective: The current treatment for locally advanced gastroesophageal junction (GEJ) adenocarcinoma consists of neoadjuvant treatment (NA T) followed by surgery. Preoperative chemotherapy (CT) and radio-chemotherapy (RCT) are both valid options, but comparative data to support the optimal treatment remain scarce. This study aimed to assess the efficacy of RCT and CT to achieve a complete pathologic response (CPR) for locally advanced GEJ adenocarcinoma. Secondary endpoints were R0 resection rates, postoperative complications, long-term survival and recurrence.
Methods: All consecutive patients with locally advanced GEJ adenocarcinoma treated with CT or RCT followed by oncologic surgical resection from 2009 to 2018 were included. Histopathologic response to treatment was assessed with the Mandard tumor regression score (TRG), defining CPR as TRG 1. Comparative analysis was performed with the x2 or Fisher’s test for discrete, and Mann-Whitney-U test for continuous variables. Overall and disease-free survival were compared with the Kaplan Meier method and log-rank test. Multivariate analysis was performed to define independent predictors of CPR, and long- term survival (logistic and Cox regression respectively).
Results: Among the 94 patients (n=79 (84%) male, median age 62 years [IQR 9.7]), 67 (71.3%) received preoperative RCT and 27 (28.7%) received CT. Baseline demographics and pretreatment tumor stages were comparable. Surgical approach was thoracoabdominal Lewis resection in 95.5% RCT and 81.5% CT patients (P=0.085). Although CPR was more frequent in the RCT than the CT group (13.4% vs 7.4%, P=0.009), R0 resection rates were similar (72.1% vs 66.7%, P=0.628). There was a trend to higher ypN0 stage in the RCT group (55.2% vs 33.3%; P=0.057). Postoperatively, RCT patients presented more cardiovascular complications (35.8% vs 11.1%; P=0.017), although overall morbidity was similar (68.6% vs 62.9%, P=0.988). Median follow-up was 30 months [95%CI 21.3-38.8mo] for all patients. 5-year overall survival was comparable (61.1% RCT vs 75.7% CT, P=0.259), as was 5-year disease-free survival (33.5% RCT vs 22.8% CT, P=0.763). Isolated loco-regional recurrence occurred in 2.9% RCT vs 3.7% CT patients (P=0.976). NAT type was not an independent predictor for CPR nor for long-term survival in multivariate analysis.
Conclusion: Patients with locally advanced GEJ adenocarcinoma demonstrated higher rates of CPR after RCT compared to CT, and a trend to a better locoregional lymph node control although this did not translate in a significant survival benefit or decreased recurrence rate.
gastroesophageal adenocarcinoma, neoadjuvant radio-chemotherapy, perioperative chemotherapy, tumor regression grading, overall survival
Create date
07/09/2021 14:13
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08/12/2022 7:52
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