Chemoradiation as medical treatment for esophageal cancer. Is surgery always necessary?

It is now proven that preoperative chemotherapy (CT) and chemoradiation (CRT) increase R0 resection rate and overall survival. Moreover, CRT results in about 30% pathologic complete response. Indeed two randomized trials showed that survival was similar after definitive CRT or after CRT and surgery in locally advanced esophageal squamous cell cancer, despite more frequent local recurrences. In one of these trials (FFCD 9102), only clinical responders were randomized between surgery and no surgery, therefore clinical nonresponders could be operated on without delay. Indeed, survival of randomized patients and nonrandomized operated patients was not different. Evidence of benefit of surgery is poorer in case of delayed recurrence. Only small non-randomized studies tackled the issue: R0 resection rates ranged from 50 to 87%, 5-year survival rates from 0 to 33% and operative mortality from 12.5 to 25%. A radical change in the strategy against locally advanced esophageal cancer is upcoming: to start therapy with curative CRT and perform surgery only in non-responders and in case of operable loco-regional delayed relapse. Before recommending this strategy, the benefit of delayed salvage resection should be assessed in a prospective strategic randomized trial, currently in preparation by the FFCD and the FRENCH.