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Ann Thorac Surg 2005;79:391-397
© 2005 The Society of Thoracic Surgeons

Research in Aging Award

Preoperative Chemoradiotherapy Prior to Esophagectomy in Elderly Patients is Not Associated With Increased Morbidity

David C. Rice, MB, BCha,*, Arlene M. Correa, PhDa, Ara A. Vaporciyan, MDa, Nidhi Sodhi, MDa, W. Roy Smythe, MDa, Stephen G. Swisher, MDa, Garrett L. Walsh, MDa, Joe B. Putnam, Jr, MDa, Ritsuko Komaki, MDb, Jaffer A. Ajani, MDc, Jack A. Roth, MDa

a Department of Thoracic and Cardiovascular Surgery, Houston, Texas
b Department of Radiation Oncology, Houston, Texas
c Department of Gastrointestinal Oncology, University of Texas M. D. Anderson Cancer Center, Houston, Texas

Accepted for publication August 5, 2004.

* Address reprint requests to Dr Rice, University of Texas M. D. Anderson Cancer Center, Department of Thoracic and Cardiovascular Surgery, 1515 Holcombe, Unit 445, Houston, TX 77030 (E-mail: drice{at}mdanderson.org).

Presented at the Fortieth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 26–28, 2004.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 DISCUSSION
 References
 
BACKGROUND: Preoperative chemotherapy and radiation therapy are often administered to patients with esophageal cancer. Despite an aging population, little data exist regarding feasibility of preoperative therapy in elderly patients.

METHODS: Between January 1997 and December 2002, 312 consecutive patients underwent esophagectomy for esophageal cancer at our institution. Outcomes of patients 70 years old, who underwent preoperative therapy (n = 35; group II), were compared with those of patients who did not (n = 39; group I) and with those of patients younger than 70 years old who received preoperative therapy (n = 165; group III).

RESULTS: The median age was 75 years old for group I and 72 years for group II (p < 0.001). The patients in group II were of more advanced clinical stage (p < 0.001). There were no differences in performance status, comorbidities, or preoperative symptoms between the two groups. Similar proportions of patients in the groups I and II underwent a transhiatal approach (52.5% vs 42.8%, p = not significant [NS]). Perioperative mortality for groups I and II was 0% and 3%, respectively (p = NS). Group II received more perioperative blood transfusions (71.4% vs 48.7%, p = 0.047). There were no differences in the rates of postoperative cardiac, pulmonary, neurologic, gastrointestinal, or anastomotic complications. Compared with group III, group II patients had higher rates of postoperative atrial arrhythmias (p = 0.013) and perioperative blood transfusions (p = 0.004).

CONCLUSIONS: Elderly patients receiving preoperative therapy for esophageal cancer do not have an increased incidence of major postoperative complications. Elderly patients receiving preoperative therapy are more likely to develop postoperative atrial arrhythmias and require transfusion than younger patients.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 DISCUSSION
 References
 

The Society of Thoracic Surgeons (STS) Research in Aging award is supported by funding provided by the American Geriatrics Society/Hartford Foundation. The award is presented by the STS for outstanding research in the field of aging as it relates to cardiothoracic surgery. Abstracts submitted to the STS Program Committee representing research in aging are considered for this award.

The first Research in Aging award was given to David C. Rice, MB, BCh, of the University of Texas M. D. Anderson Cancer Center in Houston. He received a monetary award of $1,500 and a certificate. Doctor Rice received the award at the STS Annual meeting in January 2004.

 

In the year 2000, the United States census counted almost 25.5 million people aged 70 years old or more, which is a 20.4% increase from 1990 [1]. In Europe, the peak age of incidence for esophageal cancer is 70 to 79 years old, and the overall incidence has doubled over the past 30 years [2]. Similar trends have been noted in the United States, where the incidence of esophageal adenocarcinoma has more than tripled in white men since the 1970s, with the highest percentage change noted in the 65- to 74-year-old age group [3, 4]. These statistics indicate that the number of elderly patients with esophageal cancer will continue to increase.

Despite aggressive surgical approaches, 5-year survival rates after esophagectomy remain extremely poor. In an effort to improve local control and reduce distant treatment failures after surgery, multimodality regimens have been investigated. To date, only two randomized trials have shown survival benefit for preoperative chemotherapy [5] or preoperative chemotherapy plus radiation therapy [6], yet preoperative treatment for esophageal cancer is widely practiced by the medical community. There are valid concerns regarding the use of such aggressive therapeutic strategies in elderly patients. Compared with younger patients, the elderly tend to have more comorbid conditions, higher rates of postoperative complications, and are more susceptible to the toxicities of certain chemotherapy and radiation therapy regimens. Furthermore, there is often a perception that the survival benefits conferred by aggressive treatment regimens are not realized in elderly patients, although the life expectancy of a 70-year-old person in the United States is relatively long (14.6 years). Such age-based treatment biases may be detrimental to many elderly patients if they lead to appropriate cancer therapies being denied [7–9].

Because the feasibility of multimodality preoperative treatment in elderly patients with esophageal cancer has not been established, we designed this retrospective study to evaluate postesophagectomy morbidity and mortality after preoperative chemotherapy and radiation therapy in patients 70 years of age or more.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 DISCUSSION
 References
 
Patient Population
From January 1997 through December 2002, 1483 patients with esophageal cancer registered at the University of Texas MD Anderson Cancer Center (MDACC). Of these, 364 were 70 years old or more. Three hundred twelve consecutive patients underwent esophagectomy, of whom 74 (24%) were 70 years old or more. For analysis, patients were divided into the following groups: group I, patients 70 years old or more who did not receive preoperative therapy (39 patients); group II, patients 70 years old or more who received preoperative therapy (35 patients); and group III, patients less than 70 years old who received preoperative treatment (165 patients).

Preoperative treatment varied according to whether it was administered as part of a phase II protocol or in an "ad hoc" manner. One hundred ninety-four patients (97%) underwent combination chemotherapy and radiation therapy, 5 patients (3%) underwent preoperative chemotherapy only, and 1 patient was treated with preoperative radiation only. Details of specific chemotherapeutic agents used, the number of chemotherapy cycles and radiation doses were recorded. The decision to administer preoperative treatment was determined by the treating physician, and was based on tumor stage, performance status, and patient acceptance.

The principle of surgery was to remove the tumor and regional lymphatics and to reestablish continuity with a mobilized stomach whenever possible. A variety of operative approaches were used, including transhiatal, transthoracic (Ivor Lewis), and three-incision esophagectomy, using standard techniques. The gastroesophageal anastomosis was performed using either stapled or hand-sewn techniques, according to the surgeon's preference. Most patients had a feeding jejunostomy placed at the time of surgery.

Patients were either immediately extubated at the completion of the procedure and admitted to a monitored floor setting or kept intubated overnight in the intensive care unit. Postoperative care was standardized according to a postesophagectomy patient care pathway and was identical for patients receiving and those not receiving preoperative treatment. Patients fasted until a modified barium swallow study performed on the seventh to tenth postoperative day showed no evidence of leak. Patients were then started on a mechanical soft diet.

Data Collection and Analysis
All patient data including preoperative, operative, postoperative, and follow-up information was collected prospectively and entered into a computerized database with prospectively defined database elements and monthly quality assurance review. Details of the specific chemotherapy and radiation therapy regimens were not part of the database; therefore this information was collected in a retrospective fashion from the medical charts. All data were retrospectively analyzed. Details of why individual patients did or did not undergo preoperative treatment were not reliably recorded in the medical records and therefore were not included in the analysis.

The differences between groups were tested for significance by the {chi}2 test or by Fisher's exact test for categorical variables and Student's t test for continuous variables. Data on patients 70 years old or more were analyzed according to whether the patients received preoperative therapy or not. In addition, data on patients 70 years of age or more who received preoperative therapy were compared with those of patients less than 70 years old who had induction treatment. Statistical significance was defined as a p value less than 0.05. All statistical analyses were performed using SPSS software (SPSS Inc., Chicago, IL). A logistic regression model was constructed with occurrence of a major complication as the dependent variable. Any in-hospital death, pneumonia, reintubation, tracheostomy, acute respiratory distress syndrome, empyema, readmission to hospital, readmission to an intensive care unit (ICU), myocardial infarction, new cardiac arrhythmia, anastomotic leak, recurrent laryngeal nerve injury, new central neurologic event, new renal failure, sepsis, multiple organ failure, reoperation, or small bowel obstruction was defined as a major event. The covariates included in the model were variables identified on univariate analysis as having a p value less than 0.25 and included age at surgery, American Society of Anesthesiology Risk Scale (ASA) classification, pain, reflux, coronary artery disease, diabetes, current alcohol use, histology, clinical, and pathologic stage. Stepwise backwards elimination using a Wald statistic with a removal p value of 0.10 was performed.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 DISCUSSION
 References
 
Patient Population
During the past decade at MDACC there has been a statistically significant increase in the percentage of registered elderly patients with esophageal cancer. From January 1997 through December 2002, 312 consecutive patients underwent esophagectomy for primary esophageal cancer. Of these, 74 were aged 70 years or more at the time of surgery. Preoperative demographic data are summarized in Table 1. Group I patients were slightly older than group II patients (mean age 76 vs 73 years old, p < 0.001) but were similar with respect to sex, performance status, comorbidities, and symptoms. Clinical stage distribution between the two groups was significantly different, with more early-stage cancers in group I (p < 0.001) (Table 2). There were no differences in clinical or pathological stage between groups II and III. Patients in group III were less likely to have had a history of angina or cardiac arrhythmias but were otherwise similar to group II in ASA classification and symptoms. Comparison of clinical stage with pathological stage is listed in Table 2. The final postoperative stage was significantly lower than the initial clinical stage in patients who underwent preoperative therapy (groups II and III, p < 0.001) but was higher than the initial clinical stage in group I (p = 0.013).


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  		Table 1. Patient Characteristics and Comorbid Conditions
 

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  		Table 2. Tumor Histology, and Clinical and Pathologic Staging
 
Preoperative Treatment
Preoperative therapy was administered to 200 patients (64%) overall. Three patients (9%) in group II and 2 patients (1%) in group III underwent preoperative chemotherapy without radiation. One patient in group III received preoperative radiotherapy without chemotherapy. The remaining 194 patients (97%) received both preoperative chemotherapy and radiation therapy. One hundred forty-four patients (72%) underwent preoperative therapy at MDACC; 85 of them (59%) were enrolled in phase II clinical protocols. The most common preoperative chemotherapy regimen consisted of 5-fluorouracil and a platinum agent. Taxanes were also frequently incorporated into the treatment regimen. Radiation was usually administered in daily fractions of 1.8 Gy for a total dose of 45 to 50 Gy. Chemotherapy was usually administered concurrently with radiation therapy but the exact sequence depended on the treating physician's preference or on the clinical protocol.

There was a significant difference between groups in the chemotherapy and radiation therapy regimens used. Triple-agent regimens were significantly more common in group III whereas double agent regimens were more common in group II. Preoperative treatment was administered in the setting of a clinical phase II protocol in 79 younger patients (48%) of but in only 6 older patients (17%; p = 0.001).

Surgical Outcomes
There were no statistically significant differences in operative approach between the three groups of patients, although patients in group III tended to have undergone more three-stage resections than did patients in group II (22% vs 11%, p = 0.076; Table 3). Mean operative blood loss, operative time, number of ventilator days, length of ICU stay and hospital stay were similar. There was one death in group II (3%). This patient developed bowel obstruction, pneumonia, and sepsis and eventually died of multiple organ failure. There were seven (4%) deaths in group III, including two deaths from myocardial infarction, two from aspiration pneumonia, two from intraabdominal sepsis, and one from multiple organ failure in a patient with carcinomatosis who required reoperation for a large bowel obstruction and subsequently developed a fatal pneumonia. There were no differences in 30-day and in-hospital mortality between groups I and II or between groups II and III.


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  		Table 3. Operative and Postoperative Data
 
Table 4 summarizes the univariate analysis of postoperative events. Pulmonary complications were the most commonly encountered event but there were no significant differences between groups. The only statistically significant difference in postoperative events noted between groups I and II was that group II patients had a higher need for perioperative blood transfusions (71% vs 49%, p = 0.047), despite the fact that there was no significant difference in their preoperative hemoglobin levels. Group II patients also had higher need for perioperative blood transfusions (71% vs 45%, p = 0.004) plus a higher incidence of postoperative atrial arrhythmias than did group III patients (34% vs 15%, p = 0.008). There was an insignificant trend towards a higher incidence of anastomotic leak between these two groups (20% vs 9%; Table 4). Of the seven anastomotic leaks noted in group II, two were subclinical and healed with conservative measures only. Three patients in group II developed cervical anastomotic leaks following transhiatal esophagectomy that resolved with open drainage of the neck incision, 1 patient required thoracotomy for a contained intrathoracic leak that subsequently fistulized to the left main bronchus, and another patient experienced necrosis of the gastric conduit following transhiatal esophagectomy and underwent resection of the conduit with cervical esophagostomy.


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  		Table 4. Postoperative Mortality and Complication Rates
 
We performed multivariate logistic regression analysis on all factors that were significant on univariate analysis but we were unable to find a significant association between preoperative therapy and either mortality or major postoperative events in older patients. Similarly, for patients who underwent preoperative treatment, age 70 years old or more was not a statistically significant predictor of mortality or postoperative complications.

Long-Term Survival
Long-term survival was analyzed for groups II and III. Patients in these groups all received preoperative therapy and were of similar clinical and pathological stage. Median, 1-year and 3-year survival rates for group II were 34 months, 80% and 43% respectively, and 42 months, 79% and 52%, p = NS, for group III (Fig 1).



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  		Fig 1. Overall survival of patients 70 years of age or older who received preoperative therapy (group II) and patients less than 70 years of age who received preoperative therapy (group III), p = not significant (NS).

 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
DISCUSSION
 References
 
Reluctance to subject elderly patients with esophageal cancer to definitive surgical therapy, even those who are medically fit, has partially arisen from reports in the medical literature documenting high perioperative mortality and postoperative complication rates [10, 11]. Improvements in preoperative physiologic screening and conditioning, intraoperative management, and postoperative care have lowered the operative risk, and most recent studies have demonstrated that esophagectomy can be accomplished safely in elderly patients. For example, Ellis and colleagues [12] compared data on 147 patients 70 years old or more with those on 358 younger patients and found no statistically significant difference in postesophagectomy mortality rates (5.3% vs 2.4%, respectively). Similarly, Bonavina and associates [13] reported an operative mortality rate of 3.3% on 403 patients 65 years old or greater, whereas Johansson and Walther [14] described no operative deaths in a group of 50 elderly patients who underwent esophagectomy. Our overall operative mortality rate of 1.3% in elderly patients (one death among 74 patients) is also low and further supports the argument that advanced age should not preclude esophagectomy in elderly patients who are otherwise healthy.

The role of preoperative therapy in esophageal cancer remains controversial. In more than 10 randomized trials performed to date only two have demonstrated that preoperative therapy results in a statistically significant survival benefit [8, 9, 15–23]. However, there is a trend toward improved survival in the preoperative therapy arms of virtually all randomized trials, and rates of complete response are consistently 20% to 30%. Preoperative therapy for esophageal cancer therefore deserves further investigation, ideally in clinical trials. Unfortunately, representation of elderly patients in clinical trials is poor [24], which is confirmed by our finding that the percentage of elderly patients treated in our clinical protocols was significantly lower compared to younger patients. The incidence of esophageal cancer in elderly patients will probably increase. Therefore, it is important that they be encouraged to enroll in future clinical therapeutic trials.

There are concerns about the safety of esophagectomy after preoperative therapy, primarily because of the potential for leukopenia, anemia, anorexia and weight loss, and the technical difficulty of performing esophagectomy when there is periesophageal inflammation related to chemotherapy and radiation therapy. However, of the seven randomized preoperative chemotherapy and radiation therapy trials performed to date, only one has reported a significant increase in surgical mortality and complications related to preoperative treatment [16]. In addition, several retrospective studies have shown that esophagectomy may be safely performed after preoperative therapy. Doty and colleagues [25] reported a mortality rate of 0.8% in 120 patients who underwent chemotherapy and radiation therapy followed by esophagectomy. Complications occurred in 37%, of which pulmonary events and arrhythmias were the most frequent (9% and 7.5%, respectively). In a recent review of 108 patients undergoing preoperative therapy and esophagectomy at the Mayo Clinic, Donington and asssociates [26] reported an overall mortality rate of 3.7% and a complication rate of 47%. Atrial arrhythmias and pulmonary complications were most frequently observed (25% and 19%, respectively).

Our data reveal similar rates of mortality (3%) and major complications (51%) in elderly patients who underwent preoperative therapy. Furthermore, we demonstrated that the only event that was more frequent among elderly patients who underwent preoperative treatment was the need for perioperative blood transfusions. Although the reasons for this are unclear, it is likely that a lower threshold for transfusing elderly patients with anemia and possibly a reduced erythropoetic response following chemotherapy may have played a role. Like the studies mentioned above, pulmonary events and atrial arrhythmias were the most frequently observed complications (49% and 34%, respectively). In a recent analysis of 2588 patients undergoing major noncardiac thoracic procedures, Vaporciyan and coworkers [27] demonstrated that increasing age, prior history of atrial arrhythmia, and intraoperative transfusion were independent risk factors for the development of postoperative atrial fibrillation. In our present study elderly patients who underwent preoperative therapy were more likely to have had a previous history of atrial arrhythmia and to have received perioperative blood transfusions than were younger patients, which may explain the higher incidence of postoperative atrial arrhythmia in this population.

The demonstration that preoperative therapy followed by esophagectomy is feasible in elderly patients also requires evidence that it is effective before such a treatment strategy can be advocated. Despite reports of older patients having shorter survival after esophagectomy for esophageal cancer than younger patients [17], we found that the efficacy of preoperative therapy was not dependent on patient age. The median survival of elderly patients was not significantly different from that of younger patients (34 vs 42 months, respectively), survival curves were parallel, and downstaging of tumors occurred in similar proportions of elderly and younger patients who underwent preoperative therapy. Other authors have also recently reported that survival among elderly patients is equivalent to that of younger patients following esophagectomy [13, 14, 28].

In conclusion, esophagectomy can be safely performed in healthy elderly patients following preoperative therapy. Compared with younger patients, elderly patients undergoing multimodality therapy have higher rates of blood transfusion and atrial arrhythmia. However, mortality and major complication rates are similar. Because age does not determine treatment efficacy, it is reasonable to consider preoperative chemotherapy and radiation therapy before esophagectomy in medically fit elderly patients. Because the survival benefit of preoperative treatment for esophageal cancer is still unproven, it should ideally be administered in the setting of a clinical trial.


   DISCUSSION
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 DISCUSSION
References
 
DR THOMAS J. WATSON (Rochester, NY): I would like to congratulate Dr Rice and his colleagues from M. D. Anderson on their outstanding work regarding this important topic. I also want to congratulate them for receiving this meeting's aging award, established to recognize meritorious work on issues regarding care of the elderly.

National Cancer Institute (NCI) SEER data from 1996 to 2000 demonstrate the median age at diagnosis of esophageal cancer to be 70 years old, a number likely to increase in the future. Of note, the average life expectancy of a 70-year-old in this country is presently 14.6 years. For the vast majority of elderly patients with esophageal malignancy, their cancer, not their age, is the life-limiting factor.

The role of combined modality therapy for potentially resectable esophageal cancer is controversial. Despite the lack of conclusive data, many centers continue to treat patients with esophageal cancer using a multimodality approach, whether it is on or off a formal clinical trial. Of the seven published randomized trials to date that have assessed combination chemotherapy and radiation before esophagectomy, most have suggested no survival advantage to the more aggressive approach, but also no significant increase in perioperative morbidity or mortality. These trials, however, have generally excluded individuals over age 70 or 75, and outcomes data in the elderly population, both in terms of safety and efficacy of therapy, have been lacking.

The group from M. D. Anderson presented today an impressive series of 74 patients age 70 or greater undergoing esophagectomy for cancer at their institution. Outcomes in elderly individuals receiving multimodality therapy, which generally consisted of preoperative combined chemotherapy and radiation, followed by esophagectomy, were compared to two control groups: a cohort of elderly patients undergoing esophagectomy alone and a cohort of younger patients receiving multimodality therapy.

The study group held up quite well in these comparisons. No significant differences were seen in major perioperative complication rates other than an increased need for perioperative blood transfusions compared with both control groups and a higher rate of postoperative atrial arrhythmias compared to younger individuals.

As elderly patients were not randomly assigned to their type of treatment, however, a potential exists for selection bias, with only healthier patients undergoing the more aggressive combined approach. Bias may be evident in the fact that patients receiving multimodality therapy were, on average, approximately 3 years younger than those undergoing surgery alone. Also, patients less than 70 years old were much more likely to have received three-drug combinations of chemotherapy, while older patients generally received two-drug combinations.

An important omission from this study was the lack of data regarding morbidity and mortality during the course of the actual preoperative treatment. This study looked only at the influence of neoadjuvant therapy on perioperative morbidity. Perhaps the title of the report would best be changed to reflect this fact. Clearly, for the data ultimately to be helpful in clinical decision making, the aggregate morbidities encountered during the entire course of multimodality therapy need to be considered when making comparison to esophagectomy alone.

The overall operative mortality for patients age 70 years old or greater was an impressively low 1.3%, representing a single death in their series. This low mortality stands as a testament to the quality of care delivered at the author's institution, affirms the low mortality reported by other authors in recent reports of esophagectomy in elderly individuals, and supports the notion that esophagectomy should not be denied to elderly individuals who are otherwise appropriate surgical candidates and physiologically fit. Combined modality therapy for esophageal cancer in all age groups deserves further study. This study suggests that esophagectomy can be performed safely in properly selected individuals after neoadjuvant therapy.

Doctor Rice, I would like to ask a few questions. Number one, are you aware of any patients initially considered candidates for esophagectomy who underwent neoadjuvant treatment and subsequently were not taken to surgery because of complications of such therapy or disease progression?

Number two, you reported survival curves for both elderly and younger individuals undergoing combined modality therapy and demonstrated that age did not appear to be a factor in survival. Did you calculate a similar survival curve for elderly patients undergoing esophagectomy alone? On the basis of your experience, should future clinical trials of multimodality therapy for esophageal cancer include elderly individuals? Finally, is combined modality therapy in the elderly a reasonable alternative outside of a formal clinical trial setting?

Once again, I want to congratulate you on a fine presentation of this important and previously underreported topic. I thank the Society for the opportunity to discuss this manuscript.

DR RICE: Thank you, Dr Watson, for your kind remarks. I will answer your first question, whether or not we knew of any patients who received neoadjuvant therapy who suffered complications related to that therapy and, therefore, did not undergo surgery. Unfortunately, given the retrospective nature of this study, it was impossible to get that data. The majority of elderly patients were treated in an ad hoc protocol; in fact, only 17% actually were treated on protocol. Furthermore, the majority, about 55% of these elderly patients, received chemotherapy and radiation therapy at institutions elsewhere, and then they were referred to M. D. Anderson Cancer Center for their surgery. So it is really impossible for us to garner that information, but that is an extremely important point that you bring up and all the more reason for why we need to administer chemotherapy and radiation in a preoperative fashion for elderly patients in the setting of a prospective trial so that the overall denominator can be found.

Regarding the survival of group I patients, I did not compare this, in the presentation at least, to the other two groups, because the initial preoperative clinical stage of these patients was completely different, with many more stage I patients and early stage II patients in group I. However, there was no significant difference in survival when you compare the survival of group I to group II. The median survival for this group had not been reached yet, however, the 3-year survival was 65% in this group.

Finally, should future trials include elderly individuals? The answer to that, in my mind, is a resounding yes. Elderly individuals represent approximately 50% to 60% of the overall population with cancer in this country, and if you look at most of the prospective randomized trials, really for any cancer, the elderly population is grossly underrepresented; usually 20% of patients in clinical trials are elderly. So I think that it is extremely important that the elderly population be encouraged to be enrolled in prospective trials.

Whether or not chemotherapy and radiation preoperatively should be administered ad hoc is a difficult question to answer. From a scientific standpoint, probably not; however, we have noticed seemingly good survival at least with preoperative therapy. So I guess my clinical bias would be yes, that that patient should at least be considered for this. The key is that we are dealing with a highly selected group of elderly patients here. The majority of elderly patients probably are not good candidates for neoadjuvant therapy. The groups that we report on here have been extensively screened physiologically and are in good shape.

I would like to thank the Society again for the privilege of presenting this today.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 DISCUSSION
 References
 

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A. Ruol, G. Portale, C. Castoro, S. Merigliano, M. Cagol, F. Cavallin, V. C. Sileni, L. Corti, S. Rampado, M. Costantini, et al.
Effects of Neoadjuvant Therapy on Perioperative Morbidity in Elderly Patients Undergoing Esophagectomy for Esophageal Cancer
Ann. Surg. Oncol., November 1, 2007; 14(11): 3243 - 3250.
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David C. Rice
Ara A. Vaporciyan
W. Roy Smythe
Stephen G. Swisher
Garrett L. Walsh
Jack A. Roth
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