Beyond Routine Staging Investigations, How to Choose the Right Patients for Oesophagectomy? (#54)
Oesophagectomy is considered the cornerstone of intentionally curative treatment for oesophageal cancer. Reported 5-year survival rates range from 6 to 50%, but rarely exceed 40%. In more than half of the patients, locoregional recurrence and/or distant metastases will develop, mostly within 2-3 years after surgery. Patients with distant dissemination can potentially only be cured by effective systemic therapy. With present chemotherapy regimens cure is hardly expected. Hence, better tools for selecting patients who will benefit from surgery to cure the disease is needed. Improved staging modalities are currently under evaluation including PET-CT scanning with new radiopharmaceutical compounds. Magnetic resonance imaging has emerged as a new staging modality for oesophageal cancer but is likely not able to detect micrometastases. Another strategy is to intensify staging by repeating investigations over time. The additional value of a second PET-CT after completion of neoadjuvant therapy was recently shown. Development of clinical metastatic disease during neoadjuvant therapy was detected by PET-CT in 8% of esophageal cancer patients, suggesting an additional value of a second PET-CT in order to prevent unnecessary surgical resections. Much is expected from genetic profiling of cancers but so far this has not been tested in clinical trials. A wait and see approach in patients after neoadjuvant chemoradiation (CRT) is a potential strategy to better select patients that truly need oesophagectomy. In the neoadjuvant CRT arm of the Dutch CROSS trial (van Hagen et al. NEJM 2012), 49% of patients with a squamous cell carcinoma and 23% of patients with an adenocarcinoma had a pathologically complete response in the resection specimen. These results raise the questions whether a surgical resection had been beneficial in these patients and whether some patients had already been cured locoregionally by the neoadjuvant treatment. This points towards a more individualized approach to surgical resection after routine staging and neoadjuvant CRT; a new approach in which possibly not every patient with oesophageal cancer needs a resection after completion of neoadjuvant CRT to achieve long-term survival. In this surgery as needed approach, patients will undergo extensive surveillance after completion of neoadjuvant CRT. Surgical resection will be offered only to those patients, in whom a locoregional recurrence is highly suspected or proven, without any signs of distant dissemination present. A comparable approach was already tested in phase II trials for rectal cancer with very impressive results.