Do Any Subgroups of Resected Biliary Tract Cancers Patients That Benefit the Most from Adjuvant Chemoradiation Therapy?
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LETTER – HEPATOBILIARY TUMORS
Do Any Subgroups of Resected Biliary Tract Cancers Patients That Benefit the Most from Adjuvant Chemoradiation Therapy? Wen-Jie Ma, MD, and Rong-Xing Zhou, MD Department of Biliary Surgery, West China Hospital of Medicine, Sichuan University, Chengdu, Sichuan, People’s Republic of China
To the Editor, We read with interest the recent publication by Dee et al., which presents a retrospective, single-institutional series of 80 patients with resected biliary tract cancers (BTCs) conducted from 2007 to 2017.1 Those researchers found that the locoregional failure (LRF) rates remained significant despite adjuvant chemoradiation therapy (CRT). Lymph node positivity may be associated with increased risk of LRF. Positive margins were not associated with greater LRF, suggesting that CRT may mitigate LRF risk for this group. An association between LRF and higher rates of subsequent biliary interventions was observed, which may yield significant morbidity. It is indeed an interesting series in the field, and we congratulate the authors for their clinically relevant contribution; however, several issues need further consideration and discussion. First, Dee et al. thought that CRT may mitigate the increased risk of LRF for patients with R1 resection, who were found to have LRF rates similar to those for patients with R0 resection (18.6% for R0 and 32.8% for R1; P = 0.48). Thus, the authors support to the use of CRT for patients with BTCs, particularly after R1 resection. However, recent studies have suggested a modest survival benefit from adjuvant CRT for subsets of BTCs.2,3 Due to the nature of their retrospective studies, their conclusion needs to be confirmed by randomized research. Furthermore, the SWOG0809 found no significant difference
Ó Society of Surgical Oncology 2020 First Received: 6 August 2020 Accepted: 13 August 2020 R.-X. Zhou, MD e-mail: [email protected]
between patients with R0 and R1 resections in terms of 2-year LRF-free survival (R0, 91%; R1, 84%).4 Additionally, in Horgan et al.’s meta-analysis, they described the survival benefit of adjuvant radiotherapy for patients with R1 disease.5 However, given the quality of the data (mostly nonrandomized series) included in their analysis, the conclusion should be further confirmed. In our previously reported meta-analysis of randomized clinical trials of adjuvant chemotherapy for resected BTCs, R1 resected BTCs did not achieve significant survival benefits from adjuvant chemotherapy.6 Thus, a well-designed, prospective, multicenter, randomized, controlled trial is needed to investigate the role of adjuvant CRT in R1 resected BTCs patients. Second, the authors thought that resected BTCs patients with positive lymph nodes may benefit the most from adjuvant therapy. Unfortunately, in our previously reported meta-analysis, there is no statistically significant subgroup effect for resection margin status and lymph node status on the survival benefits of adjuvant therapy in resected BTCs patients. Only the chemotherapy regim
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