BACKGROUND INFORMATION:
Esophageal carcinoma is one of the most aggressive malignant diseases. At present, neoadjuvant chemotherapy and chemoradiotherapy are regarded as the standard modalities for the treatment of locally advanced esophageal cancer. Patients receiving neoadjuvant therapy and reaching a pathological complete response have better survival outcomes and a lower recurrence risk. In those not achieving pathological CR, nivolumab is recommended as per NCCN, ESMO, and ASCO guidelines. The advantages of adjuvant Nivolumab were shown in the CheckMate 577 trial. At a median follow-up of 24.4 months, the median disease-free survival was twice as long with nivolumab (22.4 versus 11 months; HR for disease progression or death was 0.69). The overall survival data were not sufficient. While it was well tolerated, it is unclear whether the use of this treatment is feasible in our developing country, as most patients are not able to afford this expensive medication.
METHODS AND RESULTS:
At our institution, we conducted a retrospective study of esophageal squamous cell carcinoma patients who underwent the neoadjuvant CROSS protocol followed by surgery for a period of 2 years. Of the total forty-three (43) esophageal squamous cell carcinoma patients, seventeen (17) had a complete pathologic response. Out of the twenty-six (26) patients with residual disease, only one (1) received adjuvant nivolumab. Nivolumab was well tolerated. Three patients underwent chemotherapy, and the rest entered the follow-up period. The patient who received nivolumab is now in the follow-up period and has had disease-free survival for 40 months so far. Overall survival has not been reached yet.
CONCLUSIONS:
Among patients treated with neoadjuvant chemoradiotherapy, the majority of recurrences occur within one year. The pattern of recurrence was distant, locoregional, or both in 60, 30, and 10% of patients, respectively. Although guidelines recommend nivolumab for patients with residual disease, cost constraints prevent most of them from benefitting from this treatment in developing countries like India. To ascertain what can be done to further delay recurrence and gain better disease-free survival rates, many more studies are required.
