The advantage of postoperative therapy is the knowledge of the pathological stage to appropriately select patients for therapy. The pros and cons of preoperative versus postoperative therapy are further discussed in Table 1. Table 1 Pros and Cons of preoperative versus postoperative therapy for esophageal cancer ((5)) With preoperative therapy, optimal tumor downstaging can result in complete pathological response of the tumor, portending improved survival outcomes for esophageal carcinoma. Pathological complete response (pCR) has often been used as a surrogate Inhibitors,research,lifescience,medical for efficacy of therapy and a measure by which various neoadjuvant therapies in esophageal

cancer can be compared. Rohatgi et al retrospectively analyzed 235 patients who underwent preoperative CRT for adenocarcinoma (82%) or squamous cell (18%) carcinoma of the esophagus and found that patients who experienced pCR had longer overall and Selleck GSK2656157 disease free survival rates, fewer distant metastases, and less disease recurrences Inhibitors,research,lifescience,medical (6). At 37-month follow-up, patients with pCR had a 74% overall survival, compared to 65% for those with <50% residual disease after CRT, and 40%

for those with >50% residual disease after CRT. In addition, pCR may be more predictive of survival for patients with adenocarcinoma than squamous Inhibitors,research,lifescience,medical cell carcinoma in those Inhibitors,research,lifescience,medical receiving preoperative CRT (7). Preoperative chemotherapy Investigators have evaluated multiple neoadjuvant regimens consisting of preoperative chemotherapy or perioperative chemotherapy. Despite the available studies, biases may still remain

about the benefit of perioperative chemotherapy versus CRT. RTOG 8911 compared surgery alone with chemotherapy followed by surgery, revealing no overall survival difference between the two arms. Patients who underwent less than an R0 resection had an ominous prognosis (5-year overall survival for R0 resection 32%, and R1 resection 5%) (8). Inhibitors,research,lifescience,medical Cunningham et al evaluated surgery alone compared to a regimen consisting of 3 cycles of both preoperative and postoperative epirubicin, cisplatin, and 5-fluorouracil (ECF) for resectable gastroesophageal cancer and showed significant downstaging, but pathological complete Adenylyl cyclase response rates were zero. With the addition of chemotherapy, 5-year survival was improved from 23% to 36% with chemotherapy and progression free survival was also significantly improved (9). The Medical Research Council also demonstrated a significant 2-year overall survival benefit from 34% to 43% with the addition of 2 cycles of preoperative cisplatin and 5-FU (p=0.004) (10). A meta-analysis by Urschel et al evaluated 11 randomized clinical trials including nearly 2,000 patients treated with neoadjuvant chemotherapy compared to surgery alone (11).