Complete clinical response after neoadjuvant chemoradiotherapy for squamous cell cancer of the thoracic oesophagus: is surgery always necessary?

BACKGROUND: Neoadjuvant chemoradiotherapy (CT-RT) before oesophagectomy is standard management for squamous cell carcinoma(SCC) of the thoracic oesophagus. The aim of this study was to compare the outcome of patients who had clinical complete response(CR) with neoadjuvant CT-RT + oesophagectomy with the survival of patients who had clinical CR and were not operated on. PATIENTS AND METHODS: Seventy-seven consecutive patients with SCC of the thoracic oesophagus with CR with neoadjuvant CT-RT presenting at the Regional Center of Esophageal Diseases from 1992 to 2008 were included in this retrospective study on a prospectively collected database. Thirty-nine patients underwent oesophagectomy (CT-RT + oesophagectomy), while 38(CT-RT) were not operated on because they were considered unfit for surgery or refused the operation. Patients’ outcome and survival were compared.
RESULTS: In the CT-RT + oesophagectomy group, clinical CR was confirmed after histological examination of the surgical specimen in 27/39 (69.2 %) patients. Five-year overall survival rates were 50.0 % in the CT-RT + oesophagectomy group and 57.0 % in the CT-RT group (p=0.99); 5-year disease-free survival rates were 55.5%in the CT-RT + oesophagectomy group and 34.6%in the CTRT group (p=0.15). Even after adjusting for propensity score, age, ASA and clinical stage, the treatment regimen did not show a statistically significant effect on overall survival (adjusted p=0.65) nor on disease-free survival (adjusted p=0.15).
CONCLUSION: In our group of patients with clinical CR after neoadjuvant CT-RT for SCC of the thoracic oesophagus, waiting for recurrence and then using salvage surgery did not negatively impact their survival compared to patients treated with surgery. More accurate restaging protocols are warranted to improve decision making after CR with neoadjuvant CT-RT.