Page 57 - ARNM-2-3

Advances in Radiotherapy
& Nuclear Medicine NCRT for T3N0M0 ESCC

1. Introduction selected. The inclusion criteria were: (i) tumor located in
the thoracic region, (ii) pathologically confirmed squamous
Esophageal cancer is associated with high incidence and cell carcinoma, (iii) treatment with either surgery alone or
mortality rates. Based on statistics, the 5-year survival rate NCRT + S, and (iv) a pre-T3N0M0 stage. The exclusion
1,2
for untreated esophageal cancer patients seldom surpasses criteria included: (i) the presence of other malignant
35 – 45%. At present, neoadjuvant chemoradiotherapy tumors, (ii) incomplete resection (R1 and R2), (iii) positive
1,2
(NCRT) followed by surgery is the standard therapeutic node or organ metastasis (N1-3 or M1), and (iv) missing
strategy for locally advanced esophageal cancer, according required data. A total of 443 patients were retrospectively
to the CROSS trial and the NEOCRTEC 5010 study. reviewed.
3-5
However, in the NEOCRTEC 5010 study, 33.9% of patients
in the surgery group had stage II disease, indicating that 2.2. Therapeutic strategy
few patients had T3N0M0. T3N0M0 and T2N0M0 are
4
classified as stage II based on the eighth edition of the The study population mainly underwent standard McKeown
TNM classification; however, treatment strategies may esophagectomy (n = 368) or Ivor Lewis esophagectomy
differ across studies. 6-10 Therefore, the application of the (n = 69). The research cohort was divided into two groups
NCRT treatment strategy to T3N0M0 patients remains a based on treatment: the surgery (S) group and the NCRT +
topic of debate. S group. Patients in the S group underwent surgery directly
after diagnosis, whereas those in the NCRT + S group
Mantziari et al. compared the survival outcomes received chemoradiotherapy followed by surgery. The
7
between neoadjuvant treatment combined with surgery pathologic staging of patients was determined according
(NS) and primary surgery in patients with clinical T3N0M0 to the eighth edition of the American Joint Committee on
(cT3N0M0) and found that NS had a better curative effect. Cancer (AJCC) TNM classification for esophageal cancer.
15
However, the proportion of patients with pathological N0 In the NCRT + S group, the chemotherapy regimen
(pN0) in the surgery group was small, and approximately typically included taxane combined with platinum.
64.3% of patients with lymph node (LN)-positive post- Patients received 40 – 50 Gy of external beam radiation in
operative pathology had been misdiagnosed as N0 before daily fractions of 1.8 – 2 Gy, 5 times a week, targeting the
treatment, indicating that clinical staging was not accurate. primary tumor and metastatic LNs for 4 – 5 weeks.
For this reason, the research results are controversial.
2.3. Evaluation of pre-treatment T3N0M0
In the surgery-alone group, post-operative pathological
staging typically represents the pretreatment staging. In the S group, patients with pre-T3N0M0 status were
However, in the NCRT plus surgery (NCRT + S) group, selected based on post-operative pathological reports
due to tumor downstaging after NCRT, post-operative showing pT3N0M0 and complete tumor resection (R0).
11
pathological staging often cannot accurately represent However, due to tumor downstaging after NCRT, evaluating
pretreatment staging. Moreover, staging of LNs before the actual T3N0M0 before treatment in the NCRT + S
treatment is often inaccurate. To address this issue, group was challenging. Thus, a new method was developed
7,12
many researchers have studied the effects of post-operative to accurately assess patients with pre-T3N0M0 status. First,
adjuvant therapy compared to surgery alone in patients the eighth edition of the AJCC staging criteria was used
with pathological T3N0M0 (pT3N0M0). 13,14 However, no to re-stage patients based on pretreatment endoscopic
studies have directly compared the efficacy of NCRT + S ultrasound and chest computed tomography (CT) scans.
with surgery alone in patients with pretreatment T3N0M0 Subsequently, patients with clinical stage T3 (cT3) from the
(pre-T3N0M0) status. NCRT + S group were selected, and their excised LNs were
In this study, a new method was developed to accurately subjected to pathological assessment. Based on previous
select patients with pre-T3N0M0. The objective was to studies, 16-18 a grading system was established to assess the
assess the prognostic impact of NCRT + S compared to treatment response of LNs after NCRT as follows: grade 0,
surgery alone in patients with pre-T3N0M0 esophageal no evidence of cancer involvement or regression (true
squamous cell carcinoma (ESCC), with the aim of negative LNs, Figure 1A); grade 1, complete regression
providing meaningful guidance for clinical practice. of LNs (Figure 1B); grade 2, <10% cancer residual rate in
LNs; grade 3, 10 – 50% cancer residual rate in LNs; and
2. Materials and methods grade 4, >50% cancer residual rate in LNs. Grades 2 – 4
were considered non-pathological complete response
2.1. Patient selection (non-pCR) in LNs (Figure 1C). Patients with cT3 and LN
Patients who underwent esophagectomy at Sichuan grade 0 were ultimately considered to have been accurately
Cancer Hospital between January 2008 and June 2021 were staged as pre-T3N0M0.

Volume 2 Issue 3 (2024) 2 doi: 10.36922/arnm.3821