Is surgery always necessary in esophageal cancer?

Two randomized trials showed that survival was similar after definitive chemoradiation (CRT) or after CRT and surgery in locally advanced esophageal squamous cell cancer, despite more frequent local recurrences. In one trial randomization was done at inclusion, whereas in the other trial a workup was performed after initial CRT; only clinical responders were randomized between surgery and additional CRT. Therefore, clinical non-responders could be operated on without delay. Indeed, randomized patients and nonrandomized operated patients had a similar survival, even if no response was seen on the specimen. However, evidence of benefit is poor in cases of delayed recurrence. Only small nonrandomized studies have considered this 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%; only R0 resection was associated with long survival. Therefore, the benefit of delayed salvage resection should be assessed in a prospective strategic randomized trial, after a CRT intensive enough to eradicate a sensitive tumor without increasing the risk of eventual surgery. The FFCD (Federation Francophone de Cancerologie Digestive) is working on such a trial in locally advanced operable esophageal carcinoma: CRT and systematic surgery compared with CRT followed by surgery in case of proven persistent tumor or resectable local recurrence. CRT will be improved with induction chemotherapy, new drugs, and up-to-date protracted radiotherapy.