ASO Author Reflections: Recurrence After Pathological Complete Response in Esophageal Cancer: Analysis of Risk Factors f
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Recurrence After Pathological Complete Response in Esophageal Cancer: Analysis of Risk Factors for this Unexpected Event Roberta La Mendola, MD1 , Maria Bencivenga, MD1, Lorena Torroni, MSc2, Michele Sacco, MD1, and Simone Giacopuzzi, MD, PhD1 1
General and Upper GI Surgery Division, University of Verona, Verona, Italy; 2Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
PAST In the last decades, evidence from the literature clearly showed the correlation between response to neoadjuvant treatment and survival in both locally advanced squamous cell carcinoma (SCC) and adenocarcinoma (AC) of the esophagus. The best achievable result is pathological complete response (pCR), with a 5-year overall survival (OS) and disease-free survival (DFS) higher than 50%1. PRESENT Many reports show that even in the good prognosis category of pCR, recurrences occur in 20–40% of cases.2–5 As such, risk factors for relapse in pCR patients were analyzed to better understand this unexpected event. In our study,2 we found THAT ACs relapse earlier compared with SCCs. We hypothesize that this finding is due to a higher sensibility of SCC to the most common neoadjuvant treatment schedules, leading to a delay in tumor relapse in this histotype. For this reason, we suggest that follow-up should be continued over 5 years, especially in SCCs, even in the case of pCR. The second relevant point we would like to highlight regards the site of recurrence. One-third of SCC relapses occurred at the locoregional level, raising some doubts as
Ó Society of Surgical Oncology 2020 First Received: 26 October 2020 Accepted: 27 October 2020 R. La Mendola, MD e-mail: [email protected]
to the feasibility of a ‘watch and wait’ strategy, which currently seems to represent a valid option in order to avoid unnecessary esophagectomies in SCCs with clinical complete response after neoadjuvant treatments. However, we agree with other authors that the main challenge is systemic control of the disease, both in AC and SCC, suggesting that adjuvant chemotherapy may give a survival advantage in some patients, even after the achievement of pCR, as already proposed by other authors in regard to rectal cancer.6 Considering that SCCs and ACs have different patterns and timing of recurrences, we separately analyzed the risk factors for cancer relapse in a population of 144 EC patients, according to histotype.2 Indeed, in our opinion, there is an urgent need to find the predictive factors for recurrence after pCR in EC in order to identify the ‘high-risk subpopulation’ who may benefit from additional postoperative treatment and a customized follow-up. Various clinical and pathological features have been identified as potential predictive factors for recurrence,3–5 but to date the results are still not univocal. Our analysis, in line with the study by Chao et al.,4 showed that pretreatment primary tumor stage (cT4) is an independent risk factor f
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