Patient choice of surgery or surveillance following a clinical complete response to neoadjuvant chemoradiotherapy for oesophageal carcinoma

Salvage surgery for oesophageal cancer: The need for more intensive surveillance

BACKGROUND

There is currently no consensus on the role, method or frequency of surveillance following curative treatment of oesophageal cancer; re-investigation largely relying on symptom triggers which may delay detection of recurrence and impact survival. We hypothesised that intensive surveillance with endoscopy and imaging was more likely to detect recurrent or new cancer at a curable stage and this study examined the outcomes of this surveillance policy.

PATIENTS AND METHODS

A prospective database of curatively treated oesophageal carcinoma patients was interrogated for patients with new or recurrent disease detected on surveillance and amenable to salvage surgery. Surveillance was by clinic visits and endoscopy/biopsy 3-monthly to 3 years, 6-montjhly to 5 years and yearly thereafter while computerised tomography (CT) was performed 6-monthly for the first 3 years, annually to 5 years, and subsequently as indicated.

RESULTS

Of 205 patients treated with curative intent, 24 (11.7 %) underwent salvage surgery for 27 incidences of new or recurrent cancer. The median and 5-year survival was 51.8 months and 45.8 %, which was not inferior to the entire cohort of patients treated for cure, which was 30.2 months and 32.6 % respectively (p = 0.498).

CONCLUSIONS

Intensive surveillance identified almost 12 % of patients with recurrent or second primary cancer amenable to salvage surgery, with a non-inferior outcome to the remaining cohort. Further studies will refine surveillance intervals, techniques and follow-up duration for oesophageal cancer as for other GI malignancies.

International Expert Consensus on Semantics of Multimodal Esophageal Cancer Treatment: Delphi Study

BACKGROUND

Recent developments in esophageal cancer treatment, including studies exploring active surveillance following chemoradiotherapy, have led to a need for clear terminology and definitions regarding different multimodal treatment options.

OBJECTIVE

The aim of this study was to reach worldwide consensus on the definitions and semantics of multimodal esophageal cancer treatment.

METHODS

In total, 72 experts working in the field of multimodal esophageal cancer treatment were invited to participate in this Delphi study. The study comprised three Delphi surveys sent out by email and one online meeting. Input for the Delphi survey consisted of terminology obtained from a systematic literature search. Participants were asked to respond to open questions and to indicate whether they agreed or disagreed with different statements. Consensus was reached when there was ≥75% agreement among respondents.

RESULTS

Forty-nine of 72 invited experts (68.1%) participated in the first online Delphi survey, 45 (62.5%) in the second survey, 21 (46.7%) of 45 in the online meeting, and 39 (86.7%) of 45 in the final survey. Consensus on neoadjuvant and definitive chemoradiotherapy with or without surgery was reached for 27 of 31 items (87%). No consensus was reached on follow-up after treatment with definitive chemoradiotherapy.

CONCLUSION(S)

Consensus was reached on most statements regarding terminology and definitions of multimodal esophageal cancer treatment. Implementing uniform criteria facilitates comparison of studies and promotes international research collaborations.

Active surveillance for clinical complete responders after chemoradiotherapy for oesophageal squamous cell carcinoma

BACKGROUND

Guidelines on the treatment of oesophageal squamous cell carcinoma (SCC) recommend neoadjuvant chemoradiotherapy plus surgery or definitive chemoradiotherapy. The aim of this study was to evaluate the outcome of patients with a cCR after chemoradiotherapy who underwent active surveillance.

METHODS

Patients with oesophageal SCC who were treated with chemoradiotherapy between January 2016 and June 2022 were identified from an institutional database. Survival and recurrence of patients with a cCR who underwent active surveillance were compared with those of patients who underwent planned surgery. Survival was calculated according to the Kaplan-Meier method and compared between groups using the log rank test.

RESULTS

The 37 patients who underwent active surveillance were older and tumours were more often located in the middle/upper-third of the oesophagus than in the surgery group of 57 patients. Median follow-up was 28.1 (i.q.r. 17.2-47.1) months for the active surveillance group and 20 (12.9-39.1) months for the surgery group. Overall survival was comparable between the two groups, with 3-year survival rates of 50 (95% c.i. 31 to 67) and 59 (40 to 73)% for the active surveillance and surgery groups respectively (P = 0.55). Three-year progression-free survival for patients who underwent active surveillance was better than in the surgery group: 70 (43 to 85) versus 58 (40 to 72)% (P = 0.02). Overall and progression-free survival was comparable between patients in the active surveillance group and 23 patients in the surgery group who had a pCR (ypT0 N0). The overall recurrence rate was comparable between the groups: 7 of 37 (19.4%) in active surveillance group versus 16 of 49 (32.6%) in surgery group (P = 0.26). Locoregional recurrence was noted more often in the active surveillance group and systemic recurrence in the surgery group.

CONCLUSION

Active surveillance is feasible and safe for patients with oesophageal SCC who have a cCR after chemoradiotherapy.