Chemoradiation for Patients with Resected Biliary Tract Cancers in the Adjuvant Setting: Reply to a Letter to the Editor

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LETTER – HEPATOBILIARY TUMORS

Chemoradiation for Patients with Resected Biliary Tract Cancers in the Adjuvant Setting: Reply to a Letter to the Editor Edward Christopher Dee, BS1, Morgan E. Freret, MD, PhD2, and Jennifer Y. Wo, MD1,3 Harvard Medical School, Boston, MA; 2Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; 3Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 1

TO THE EDITOR, We thank Dr. Ma and Dr. Zhou for taking the time to read our contribution, and we thank the editors for the opportunity to respond to the letter. Their commentary is well received and helps to further the important question regarding adjuvant strategies for patients with biliary tract cancers (BTCs). Our report describes a single-institution analysis of 80 patients who had resected BTCs treated with adjuvant chemoradiation therapy (CRT) from 2007 to 2017.1,2 The rates of locoregional failure (LRF) did not differ significantly between patients with R1 and R0 resections. Our findings suggest that CRT may lower the rates of LRF for patients with R1 resection to rates similar to those for patients with R0 resection. We also found that lymph node positivity was associated with increased risk of LRF, and that LRF was in turn associated with increased rates of subsequent biliary intervention and resultant morbidity. Our findings lend support to the value of adjuvant CRT for patients with BTCs, particularly for patients with R1 resection. Dr. Ma and Dr. Zhou raise an important point about the need for further prospective confirmation of the appropriate adjuvant strategy for patients with BTCs. In their metaanalysis of prospective studies, they report that adjuvant chemotherapy (ACT) may be associated with improved

Ó Society of Surgical Oncology 2020 First Received: 31 August 2020 Accepted: 31 August 2020 J. Y. Wo, MD e-mail: [email protected]

overall survival (OS) (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.77–1.01; P = 0.07) and recurrencefree survival (RFS) (HR, 0.83; 95% CI, 0.69–0.99; P = 0.04), particularly for patients treated with fluorouracil-based ACT.3 We note, however, that all five trials highlighted in their meta-analysis assessed adjuvant chemotherapy and not adjuvant chemoradiation therapy, further nuancing the question of appropriate adjuvant strategies for patients with BTCs.4–8 The prospective single-arm Southwest Oncology Group (SWOG) S0809 trial found promising survival rates associated with adjuvant chemotherapy (gemcitabine and capecitabine) followed by CRT (2-year OS: 67% for R0, 60% for R1; median survival: 34 months for R0, 35 months for R1; 2-year LRF-free survival: 91% for R0, 84% for R1).9 The meta-analysis of Horgan et al.10 similarly lends support to adjuvant radiation for patients with R1 resections (adjuvant radiation for R1: OR, 0.33; 95% CI, 0.14–0.81; P = 0.01 vs. R0: OR, 1.26; 95% CI, 0.88–1.79; P = 0.20; difference in effect size: P = 0.006) in accordance with our findings. Because the meta-analysi

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