Title: Will Patients With Resectable Esophageal Cancer Be Spared Esophagectomy?
Abstract: We read with great interest the study of Wang and colleagues [1Wang B.Y. Hung W.H. Wu S.C. et al.Comparison between esophagectomy and definitive chemoradiotherapy in patients with esophageal cancer.Ann Thorac Surg. 2019; 107: 1060-1067Abstract Full Text Full Text PDF Scopus (14) Google Scholar] that compared the effects of definitive chemoradiotherapy (dCRT) with esophagectomy alone in treating esophageal cancer by propensity score-matched analysis. It found that esophagectomy alone yielded significantly better overall survival (OS) than dCRT in patients with clinical stage I/II diseases, but in patients with clinical stage III diseases, esophagectomy alone yielded similar OS to dCRT [1Wang B.Y. Hung W.H. Wu S.C. et al.Comparison between esophagectomy and definitive chemoradiotherapy in patients with esophageal cancer.Ann Thorac Surg. 2019; 107: 1060-1067Abstract Full Text Full Text PDF Scopus (14) Google Scholar]. Again, their study raised the question whether patients with resectable esophageal cancer will be spared esophagectomy. Previously, we have summarized the up-to-date evidence that compared the effects of dCRT with esophagectomy in treating early-stage esophageal cancer and similar to the results of Wang and colleagues [1Wang B.Y. Hung W.H. Wu S.C. et al.Comparison between esophagectomy and definitive chemoradiotherapy in patients with esophageal cancer.Ann Thorac Surg. 2019; 107: 1060-1067Abstract Full Text Full Text PDF Scopus (14) Google Scholar], we showed that dCRT may result in worse OS and more recurrence compared with esophagectomy for patients with early-stage esophageal cancer [2Deng H.Y. Li G. Luo J. Alai G. Can definitive chemoradiotherapy be an alternative to surgery for early-stage oesophageal cancer?.Interact Cardiovasc Thorac Surg. 2019; 28: 37-40Google Scholar]. Therefore, esophagectomy should still remain to be the standard treatment for those patients with early-stage cancer. However, as for locally advanced esophageal cancer, the result from the study of Wang and colleagues [1Wang B.Y. Hung W.H. Wu S.C. et al.Comparison between esophagectomy and definitive chemoradiotherapy in patients with esophageal cancer.Ann Thorac Surg. 2019; 107: 1060-1067Abstract Full Text Full Text PDF Scopus (14) Google Scholar] should be interpreted with cautions, because they only compared the effects of dCRT with esophagectomy alone. It should be noted that neoadjuvant chemoradiotherapy followed by esophagectomy has already been proved to improve survival of patients with locally advanced esophageal cancer compared with esophagectomy alone in the ChemoRadiotherapy for Oesophageal cancer followed by Surgery Study (CROSS) trial [3van Hagen P. Hulshof M.C. van Lanschot J.J. et al.Preoperative chemoradiotherapy for esophageal or junctional cancer.N Engl J Med. 2012; 366: 2074-2084Crossref PubMed Scopus (3566) Google Scholar]. For locally advanced esophageal cancer, neoadjuvant chemoradiotherapy was reported to yielded a 3-year survival rate of approximately 58% [3van Hagen P. Hulshof M.C. van Lanschot J.J. et al.Preoperative chemoradiotherapy for esophageal or junctional cancer.N Engl J Med. 2012; 366: 2074-2084Crossref PubMed Scopus (3566) Google Scholar], which was higher than that of esophagectomy alone or dCRT from the study of Wang and colleagues [1Wang B.Y. Hung W.H. Wu S.C. et al.Comparison between esophagectomy and definitive chemoradiotherapy in patients with esophageal cancer.Ann Thorac Surg. 2019; 107: 1060-1067Abstract Full Text Full Text PDF Scopus (14) Google Scholar] (approximately 23.7% and 17.7% for the esophagectomy alone group and the dCRT group, respectively). Currently for locally advanced resectable esophageal cancer, neoadjuvant chemoradiotherapy followed by esophagectomy has become the preferred therapeutic option, whereas dCRT is only recommended for patients who decline surgery in the National Comprehensive Cancer Network guidelines for esophageal cancer [4NCCN Guidelines for Treatment of Cancer by Site: Esophageal and Esophagogastric Junction Cancers.https://www.nccn.org/professionals/physician_gls/pdf/esophageal.pdfDate accessed: December 21, 2018Google Scholar]. Therefore, for the question of whether patients with resectable esophageal cancer will be spared esophagectomy, the answer is no or at least not now. However, the study of Wang and colleagues [1Wang B.Y. Hung W.H. Wu S.C. et al.Comparison between esophagectomy and definitive chemoradiotherapy in patients with esophageal cancer.Ann Thorac Surg. 2019; 107: 1060-1067Abstract Full Text Full Text PDF Scopus (14) Google Scholar] may at least encourage more well-conducted studies to explore the actual role of dCRT in treated locally advanced esophageal cancer by directly comparing the effects of dCRT with neoadjuvant chemoradiotherapy followed by esophagectomy. Before such evidence is available, esophagectomy should still play an important role in treating resectable esophageal cancer. Comparison Between Esophagectomy and Definitive Chemoradiotherapy in Patients With Esophageal CancerThe Annals of Thoracic SurgeryVol. 107Issue 4PreviewThis study compared survival between definitive chemoradiotherapy (CRT) and esophagectomy alone among patients with locoregional esophageal squamous cell carcinoma (SCC). Full-Text PDF ReplyThe Annals of Thoracic SurgeryVol. 108Issue 3PreviewWe are glad to have the opportunity to comment on this letter from Dr Deng [1] regarding our article [2]. It is still debatable as to what the most appropriate treatments of locally advanced esophageal cancer are. The National Comprehensive Cancer Network guidelines for esophageal squamous cell carcinoma (SCC) suggested that patients with locally advanced disease are eligible for definitive chemoradiotherapy (dCRT), neoadjuvant chemoradiotherapy plus surgery (CRT-S) or esophagectomy alone [3]. Full-Text PDF