Survival Outcomes and Predictive Factors to Evaluate the Efficacy of Neoadjuvant Chemoradiation in Carcinoma Esophagus: An Institutional Experience from India.

Abstract

Aim & Objectives: Although NCRT (Neoadjuvant Chemo Radiation Therapy) followed by surgery demonstrates an increase in overall survival (OS) in locally advanced operable esophageal cancer, there is a lack of a reliable predictive factor to identify patients who are more likely to be affected by treatment toxicities or natural history of the disease. In this study, we have studied various indices like pre-treatment serum albumin, hemoglobin, Neutrophil to Lymphocyte Ratio (NLR), Platelet to Lymphocyte Ratio (PLR), Platelet to Albumin Ratio (PAR), Systemic Immune Index (SII) as independent prognostic factors in esophageal cancer, with respect to the outcomes and tumor response. Material & Methods: A total of 83 patients of esophageal cancer who were treated with Neoadjuvant Chemoradiation from 2016-2021 were evaluated in this study. All the patients were treated with 41.4 Gy / 23 # External Beam Radiation Therapy with concurrent weekly Paclitaxel & Carboplatin (CROSS Protocol). Baseline hematological parameters like PLR, NLR, PAR, SII, Serum Albumin and Hemoglobin were obtained from laboratory records. Survival outcomes were analyzed using the Kaplan-Meier method and log rank test. Chi square test was used to analyze the association with pathological complete response after NCRT. Results: The median follow-up time of the study was 42.50 months, and the median age of patients was 55 years (IQR - 45-63). The majority of the patients were squamous cell carcinoma (92.8%), and 7.2% of the patients were adenocarcinoma of the esophagus. Amongst this study group, 41 patients (49.4%) underwent surgery following chemoradiation, the rest of the patients couldn't undergo surgery. Amongst the 41 operated patients, 21 (51.2%) had pathological complete response, 13 (31.7%) had partial response, 7 (17.1%) had poor/no response to neoadjuvant chemoradiation. The median OS of a group of patients who underwent surgery (44.7 Months) was found to be significantly higher (p<0.001) than that of patients who were not operated (17.8 Months). Kaplan Meir analysis and log-rank test revealed that high pretreatment albumin and hemoglobin had statistically significant association with better OS. High PLR, low NLR, low PAR and high SII had a correlation trend with better OS. However, statistical significance couldn't be demonstrated owing to our smaller sample size. Patients with high PLR (> 180) were found to have a higher rate of pathologic complete response compared to the patients with low PLR (< 180). Conclusion: NCRT when offered to a selected subgroup of patients having operable carcinoma esophagus can give excellent survival outcomes. Patient selection should incorporate factors that look into the biology, systemic inflammatory response and baseline status of these patients. The evaluation of these factors on a larger scale prospective multicentric trials is warranted.