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Case history

image A 64-year-old man presented with a short history of progressive dysphagia and weight loss. His medical history included hypertension, obesity and chronic obstructive pulmonary disease. He was a current smoker. Investigations (endoscopy, CT, PET and endoscopic ultrasound) revealed a T3N1M0 adenocarcinoma of the gastro-oesophageal junction (GOJ). He underwent a cardiopulmonary exercise test (CPET) to establish fitness for surgery and operative risk. His oxygen uptake at estimated lactate threshold (a well-validated postoperative risk predictive variable derived from CPET) was 7.8 ml/kg/min; his oxygen uptake at peak exercise was 13.0 ml/kg/min. Due to his high risk of perioperative mortality and morbidity, the upper gastrointestinal multidisciplinary team recommended neoadjuvant chemoradiotherapy (NACRT) and a course of prehabilitation, with a delay of the time to surgery of 10 weeks after the end of NACRT.

At his initial oncology appointment, he was referred to the smoking cessation clinic and consented to NACRT, as described in the Dutch Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS),1 with a modified dose of carboplatin and paclitaxel in light of his poor baseline fitness, which he completed with no adverse events. He then undertook a tailored in-hospital supervised exercise training programme aimed to rapidly improve his fitness, and a further course of home-based exercise until surgery. A repeat CPET immediately prior to surgery showed a significant improvement in objectively measured fitness: his oxygen uptake at estimated lactate threshold was 11.0 ml/kg/min and at peak exercise it was 16.2 ml/kg/min. End-of-treatment scans showed stable disease. He underwent a laparoscopic two-phase Ivor Lewis oesophagectomy and was cared for on an enhanced recovery pathway. After 2 days in the surgical HDU he was transferred to the ward and discharged at day 9.

What treatment options exist in the neoadjuvant setting for locally advanced gastro-oesophageal cancers?

What is the evidence base for CPET as a risk stratification tool prior to major cancer surgery?

What is the relationship between objectively measured fitness and neoadjuvant cancer treatment?

What is the evidence base for prehabilitation prior to major cancer surgery?

What treatment options exist in the neoadjuvant setting for locally advanced gastro-oesophageal cancers?

The role of NACRT in oesophageal cancer has been debated for several decades. Pooled data from a number of trials suggest a definitive survival benefit for NACRT, albeit at the cost of increased postoperative morbidity and mortality.2–4 A recently published meta-analysis5 reported that patients who had received preoperative NACRT had longer overall survival (OS; HR 0.74), a higher likelihood of complete microscopic tumour resection (R0) and a greater chance of complete pathological response, together with a lower likelihood of lymph node metastasis and postoperative tumour recurrence. No difference in perioperative mortality was observed. The most convincing evidence comes from the CROSS trial, which compared NACRT plus surgery with surgery alone.1

In the CROSS trial,1 OS was significantly better in the NACRT-plus-surgery than in the surgery-alone group (median 49.4 months ...

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