Headline: Which is better, the CROSS regimen or perioperative FLOT for esophageal adenocarcinoma?
The Study: We’ve previously seen results from the Neo-AEGIS trial that compared perioperative chemo (a mix of ECF and FLOT) with the CROSS regimen of 41.4 Gy with concurrent carboplatin and paclitaxel. In Neo-AEGIS, there were no differences in survival outcomes between arms, and several treatment response outcomes favored CRT. ESOPEC was another randomized trial that more directly compared the FLOT regimen and the CROSS CRT regimen. It randomized 428 patients with resectable, locally advanced (80.5% cT3-4, 79.7% cN+) esophageal adenocarcinoma to perioperative FLOT (4 cycles before surgery and 4 cycles after) or CRT (41.4 Gy in 23 fractions with 5 cycles of carboplatin and paclitaxel). At 3 years, the rate of OS was significantly higher with FLOT (57.4% v 50.7%). Median OS was 66 months after FLOT compared to 37 after CRT. The pathologic complete response rate was 19.5% with FLOT versus 13.5% with CRT. FLOT was clearly superior to CRT alone in ESOPEC, but how would it compare to the current standard of CRT followed by adjuvant immunotherapy? Also, could outcomes be even better if radiation were integrated into the perioperative chemo approach? Last, what will become the optimal treatment approach for unresectable disease?
TBL: For patients with locally advanced, resectable esophageal adenocarcinoma who can tolerate the regimen, perioperative FLOT results in better OS than neoadjuvant CRT alone without adjuvant immunotherapy. | Hoeppner, ASCO 2024
The Study: We’ve previously seen results from the Neo-AEGIS trial that compared perioperative chemo (a mix of ECF and FLOT) with the CROSS regimen of 41.4 Gy with concurrent carboplatin and paclitaxel. In Neo-AEGIS, there were no differences in survival outcomes between arms, and several treatment response outcomes favored CRT. ESOPEC was another randomized trial that more directly compared the FLOT regimen and the CROSS CRT regimen. It randomized 428 patients with resectable, locally advanced (80.5% cT3-4, 79.7% cN+) esophageal adenocarcinoma to perioperative FLOT (4 cycles before surgery and 4 cycles after) or CRT (41.4 Gy in 23 fractions with 5 cycles of carboplatin and paclitaxel). At 3 years, the rate of OS was significantly higher with FLOT (57.4% v 50.7%). Median OS was 66 months after FLOT compared to 37 after CRT. The pathologic complete response rate was 19.5% with FLOT versus 13.5% with CRT. FLOT was clearly superior to CRT alone in ESOPEC, but how would it compare to the current standard of CRT followed by adjuvant immunotherapy? Also, could outcomes be even better if radiation were integrated into the perioperative chemo approach? Last, what will become the optimal treatment approach for unresectable disease?
TBL: For patients with locally advanced, resectable esophageal adenocarcinoma who can tolerate the regimen, perioperative FLOT results in better OS than neoadjuvant CRT alone without adjuvant immunotherapy. | Hoeppner, ASCO 2024