Surveillance or resection after chemoradiation in esophageal cancer

Abstract

The treatment of locally advanced esophageal cancer continues to evolve. Previously, surgery was considered the foundation of treatment, but chemoradiation (CRT) has taken on a larger role both in the neoadjuvant setting and as definitive treatment. It has become clear that although some patients benefit from esophagectomy after CRT, a large subset of patients likely derive no benefit, and may be harmed by surgery.Some patients are cured from CRT alone and therefore do not need surgery. Another group of patients likely have metastatic disease at the time of local therapy that is just undetected on imaging and also do not benefit from surgery. A third group of patients will have persistent locoregional disease only after CRT. This last group is the subset who will actually benefit from surgery, but this likely comprises only a minority of patients with locally advanced disease. A strategy to maximize survival while minimizing unnecessary surgery is a reasonable goal, but present technology does not allow us to do this with certainty. Thus, the decision of whether to pursue resection or surveillance after CRT can be difficult as clinicians and patients try to balance the goal of maximizing the likelihood of cure against the risk of surgery and its impact on quality of life.

Treatment of Locally Advanced Esophageal Carcinoma: ASCO Guideline

“…55 After CRT, surgery is beneficial in the subset of patients who have remaining locally advanced disease but would not have value for patients harboring undetected metastatic disease or for those who have experienced a complete pathologic response after CRT. 56,57 In the CROSS trial, approximately 50% of patients with squamous cell carcinoma had a complete pathologic response after CRT, meaning no viable tumor cells were detected on histologic examination in the primary tumor or resected regional lymph nodes. Therefore, in patients with squamous cell carcinoma who respond to CRT, a selective surgery approach may be considered 24,58 where there are no signs of distant dissemination.…”

Circulating Tumor DNA Analysis for Detection of Minimal Residual Disease After Chemoradiotherapy for Localized Esophageal Cancer

“…Although the preferred treatment for localized ESCA is CRT followed by surgery, a significant subgroup of patients are medically unfit to undergo surgery or refuse it and for these patients, definitive CRT is an accepted treatment option 30,31 . In our cohort, we identified 12 patients receiving only CRT with both ctDNA and PET-CT evaluable following treatment (EAC, n = 10; ESCC, n = 2).…”

Optimal Surveillance Regimen to Identify Cancer Recurrence after Esophagectomy: Surveillance Imaging or History and Physical Examination? An Anesthesiologist's Point of View

“…1 Trimodality therapy with neoadjuvant chemoradiation followed by surgery has become the standard of care for many patients. 2 Surgical treatment of esophageal cancer can be done through an open transhiatal, transthoracic (2-stage or Ivor-Lewis) or 3-stage (McKeon) procedure. 3, In addition, with the advances in minimally invasive esophagectomy, 4 it has shown improvement in postoperative outcomes by reducing postoperative pulmonary complications.…”