Tri, tri again.

Top Line: Despite good clinical responses to chemoradiation alone, trimodality therapy remains the standard for locally-advanced esophageal squamous cell carcinoma (SCC).
The Study: The 2005 Stahl trial, one of the few randomized trials addressing the issue, demonstrated nothing shocking when the surgery component was dropped: better treatment-related mortality and worse local progression resulting in a wash in overall survival. But this trial is criticized due to the non-standard inclusion of induction chemo. This review of patients treated at a single institution in Munich aims to assess outcomes when surgery is dropped using more modern radiation techniques (read: IMRT) sans induction chemo. Over the last decade, 40 patients received trimodality therapy at a median radiation dose of 41.4 Gy and 55 patients received definitive chemoradiation at a median of 54 Gy. Of course, this wasn’t a randomized trial, so surgery was skipped due to cervical tumor location (47%), patient choice (27%), not having the best medical constitution for surgery (18%), or not having the best tumor for surgery (7%). At a median follow-up of over two years, median progression-free survival was 18 versus 13 months, primarily due to an increase in local failure rate from 10% to 38%. But on multivariate analysis, tumor control was primarily driven by proximal tumor location and not treatment modality.
Bottom Line: Trimodality therapy should still remain the standard for robust patients, but definitive chemoradiation for esophageal SCC is not a bad option for anyone at high risk of surgical mortality. | M√ľnch, Radiat Oncol 2019

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