Berend J van der Wilk1, Ben M Eyck1, Wayne L Hofstetter2, Jaffer A Ajani3, Guillaume Piessen4, Carlo Castoro5,6, Rita Alfieri6, Jong H Kim7, Sung-Bae Kim8, Heidi Furlong9, Thomas N Walsh9, Daan Nieboer10, Bas P L Wijnhoven1, Sjoerd M Lagarde1, J Jan B van Lanschot1. 1. Department of Surgery, Erasmus MC - University Medical Center, Erasmus MC Cancer Institute, Rotterdam, The Netherlands. 2. Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas. 3. Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas. 4. University of Lille, Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Lille, France. 5. Division of Upper Gastro-Intestinal Surgery, Department of Surgery, Humanitas University, Humanitas Clinical and Research Center-IRCCS, Milan, Italy. 6. Department of Oncological Surgery, Veneto Institute of Oncology (IOV-IRCCS), Padua, Italy. 7. Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. 8. Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. 9. Department of Surgery, Connolly Hospital, Dublin, Ireland. 10. Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, The Netherlands.
Abstract
OBJECTIVE: To compare overall survival of patients with a cCR undergoing active surveillance versus standard esophagectomy. SUMMARY OF BACKGROUND DATA: One-third of patients with esophageal cancer have a pathologically complete response in the resection specimen after neoadjuvant chemoradiotherapy. Active surveillance may be of benefit in patients with cCR, determined with diagnostics during response evaluations after chemoradiotherapy. METHODS: A systematic review and meta-analysis was performed comparing overall survival between patients with cCR after chemoradiotherapy undergoing active surveillance versus standard esophagectomy. Authors were contacted to supply individual patient data. Overall and progression-free survival were compared using random effects meta-analysis of randomized or propensity score matched data. Locoregional recurrence rate was assessed. The study-protocol was registered (PROSPERO: CRD42020167070). RESULTS: Seven studies were identified comprising 788 patients, of which after randomization or propensity score matching yielded 196 active surveillance and 257 standard esophagectomy patients. All authors provided individual patient data. The risk of all-cause mortality for active surveillance was 1.08 [95% confidence interval (CI): 0.62-1.87, P = 0.75] after intention-to-treat analysis and 0.93 (95% CI: 0.56-1.54, P = 0.75) after per-protocol analysis. The risk of progression or all-cause mortality for active surveillance was 1.14 (95% CI: 0.83-1.58, P = 0.36). Five-year locoregional recurrence rate during active surveillance was 40% (95% CI: 26%-59%). 95% of active surveillance patients undergoing postponed esophagectomy for locoregional recurrence had radical resection. CONCLUSIONS: Overall survival was comparable in patients with cCR after chemoradiotherapy undergoing active surveillance or standard esophagectomy. Diagnostic follow-up is mandatory in active surveillance and postponed esophagectomy should be offered to operable patients in case of locoregional recurrence.
OBJECTIVE: To compare overall survival of patients with a cCR undergoing active surveillance versus standard esophagectomy. SUMMARY OF BACKGROUND DATA: One-third of patients with esophageal cancer have a pathologically complete response in the resection specimen after neoadjuvant chemoradiotherapy. Active surveillance may be of benefit in patients with cCR, determined with diagnostics during response evaluations after chemoradiotherapy. METHODS: A systematic review and meta-analysis was performed comparing overall survival between patients with cCR after chemoradiotherapy undergoing active surveillance versus standard esophagectomy. Authors were contacted to supply individual patient data. Overall and progression-free survival were compared using random effects meta-analysis of randomized or propensity score matched data. Locoregional recurrence rate was assessed. The study-protocol was registered (PROSPERO: CRD42020167070). RESULTS: Seven studies were identified comprising 788 patients, of which after randomization or propensity score matching yielded 196 active surveillance and 257 standard esophagectomy patients. All authors provided individual patient data. The risk of all-cause mortality for active surveillance was 1.08 [95% confidence interval (CI): 0.62-1.87, P = 0.75] after intention-to-treat analysis and 0.93 (95% CI: 0.56-1.54, P = 0.75) after per-protocol analysis. The risk of progression or all-cause mortality for active surveillance was 1.14 (95% CI: 0.83-1.58, P = 0.36). Five-year locoregional recurrence rate during active surveillance was 40% (95% CI: 26%-59%). 95% of active surveillance patients undergoing postponed esophagectomy for locoregional recurrence had radical resection. CONCLUSIONS: Overall survival was comparable in patients with cCR after chemoradiotherapy undergoing active surveillance or standard esophagectomy. Diagnostic follow-up is mandatory in active surveillance and postponed esophagectomy should be offered to operable patients in case of locoregional recurrence.
Authors: Christopher M Jones; Heather O'Connor; Maria O'Donovan; Daniel Hayward; Adrienn Blasko; Ruth Harman; Shalini Malhotra; Irene Debiram-Beecham; Bincy Alias; Adam Bailey; Andrew Bateman; Tom D L Crosby; Stephen Falk; Simon Gollins; Maria A Hawkins; Sudarshan Kadri; Stephanie Levy; Ganesh Radhakrishna; Rajarshi Roy; Raj Sripadam; Rebecca C Fitzgerald; Somnath Mukherjee Journal: EClinicalMedicine Date: 2022-09-23