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Is There a Role for Surgery for Patients with a Complete Clinical Response after Chemoradiation for Esophageal Cancer? An Intention-to-Treat Case-Control Study

Piessen, Guillaume MD, PhD*,†,‡; Messager, Mathieu MD*,†,‡; Mirabel, Xavier MD§,¶; Briez, Nicolas MD*,†; Robb, William B. MD*,†; Adenis, Antoine MD; Mariette, Christophe MD, PhD*,†,‡

doi: 10.1097/SLA.0000000000000228
Original Articles From the ESA Proceedings

Objective: To compare the outcomes of a strategy of surveillance versus surgical resection in patients with esophageal cancer (EC) experiencing complete clinical response (cCR) after chemoradiation (CRT).

Background: In EC, it remains unclear whether a strategy of surveillance or esophagectomy is appropriate after cCR to CRT.

Methods: From 1995 to 2009, 222 operable patients had a cCR based on the results of a computed tomographic scan, endoscopy with biopsies and, when performed, a positron emission tomographic scan. Through an intention-to-treat case-control study, 59 patients treated with CRT and surveillance (group Surv) were matched 1:2 with 118 patients treated by CRT followed by surgery (group Surg), according to age, gender, tumor location and stage, histology, American Society of Anesthesiologists score, and nutritional status.

Results: The 2 groups were comparable according to the matched variables (P > 0.276). In group Surg, the postoperative mortality rate was 4.2% with evidence of residual tumor in 34.6% of specimens. In group Surv, 2 salvage esophagectomies were performed. Despite the higher dose of radiotherapy received in group Surv (50 vs 45 Gys, P = 0.003), median survival was lower (31 vs 83 months, P = 0.001), with disease recurrence that was more frequent (50.8% vs 32.7%, P = 0.021), occurred earlier (7.8 vs 19.0 months, P = 0.002) and more often locoregional (46.7% vs 16.2%, P = 0.007) in nature. Surgical resection was independently associated with less recurrence [odds ratio = 0.4, 95% confidence interval (CI): 0.2–0.8, P = 0.006] and better survival (hazard ratio = 0.5, 95% CI: 0.3–0.8, P = 0.006).

Conclusions: Survival of EC patients with a cCR after CRT is better after surgery compared to simply surveillance. In patients of low operative risk and operable disease, surgery should be considered to improve control of locoregional disease and to overcome the inherent limitations of clinical response assessment.

Although definitive chemoradiation without surgery has been suggested as a validated therapeutic strategy in esophageal cancer, we show that in complete clinical responders, surgery should be considered in patients with low operative risk, to improve both locoregional control and survival and to overcome the inherent limitations of clinical response assessment.

*Department of Digestive and Oncological Surgery, University Hospital of Lille

University of Lille—Nord de France

Inserm, Jean-Pierre Aubert Research Center, Lille Cedex

§Academic Radiotherapy Department

Gastrointestinal Oncology Department, CLCC Oscar Lambret Comprehensive Cancer Center, Lille cedex, France.

Reprints: Christophe Mariette, MD, PhD, Department of digestive and oncological surgery, University Hospital Claude Huriez, Centre Hospitalier Régional et Universitaire, Place de Verdun, F-59037 Lille, France. E-mail:

Disclosure: The authors declare no conflicts of interest.

© 2013 by Lippincott Williams & Wilkins.