Operative and Non-Operative Management of Locally Advanced Oesophageal Cancer (#61)
The treatment of oesophageal cancer has become increasingly complex over the last three decades. Historically, both primary surgery and primary radiotherapy have been used to treat (locally advanced) oesophageal cancer. These surgical- and nonsurgical treatment approaches developed independently into acceptable treatment options and improved over time due to advances in staging and improved surgical- or radiation techniques. Meta-analyses show that concurrent chemoradiotherapy (CRT) is currently recommended over radiotherapy alone as a non-surgical therapy for potentially curable oesophageal cancer. Neoadjuvant chemotherapy or CRT followed by radical oesophagectomy is the treatment of choice when surgical treatment is considered. Two European randomized controlled trials addressed an important topic that is currently under debate – definitive CRT as an alternative for neoadjuvant CRT plus surgery in oesophageal squamous cell carcinoma. Both studies demonstrate the complexity of conducting randomized controlled trials in the field of multimodality treatment for cancer of the oesophagus and have major methodological drawbacks, making it difficult to draw reliable conclusions from the data. Although the reported survival rates do not differ between both arms, definitive CRT is associated with higher locoregional recurrence rates. More recently, several high volume centers have reported their - mostly retrospective - results of selective patients treated by salvage oesophagectomy for residual or recurrent locoregional disease after definitive CRT with curative intent. Although the results are encouraging, salvage oesophagectomy is technically challenging and associated with considerable morbidity and mortality. Perhaps the next step should not focus on the addition of (salvage) surgery to a definitive CRT regimens, but rather focus on applying ‘planned’ surgery more selectively. Therefore, we are currently designing a new trial in The Netherlands that will compare the neoadjuvant CRT plus surgery arm from the CROSS trial (van Hagen et al. NEJM 2012) with a neoadjuvant CRT plus ‘surgery as needed’ arm, in which surgery will be offered only to those patients that have signs of residual or recurrent disease without any signs of distant dissemination. The main objective of this new trial will be to assess whether for patients with adenocarcinoma and squamous cell carcinoma of the oesophagus we can improve upon our results from the CROSS-trial by achieving similar overall-survival results with less patients being exposed to surgery after neoadjuvant CRT.