Critical Appraisal of Locoregional Failure and Systemic Disease Progression After Preoperative Chemoradiation of Esophageal Adenocarcinoma
Authors: Ralf Gertler, Jens T. Siveke, Marcus Feith
Journal: Journal of Clinical Oncology (2014)

TO THE EDITOR: We commend Sudo et al on their effort to retrospectively analyze their surveillance strategy of patients after trimodality therapy (TMT) for adenocarcinoma of the esophagus or esophagogastric junction (EAC). Overall, the presented results are widely confirmed by our own experience with locally advanced EAC that is treated by preoperative chemotherapy followed by surgery in our institution. Using a similarly aggressive surveillance strategy, we found 2% locoregional failure (LRF) only and approximately 20% distant metastases (with or withoutLRF)in567patientstreatedbetween2000and2010.However,wealso have some concerns about the article by Sudo et al. First, the presentation of an LRF rate of only 5% implies excellent locoregional control of EAC using preoperative chemoradiotherapy followed by surgery—that is, TMT, which the authors refer to as “successful local therapy.” Unfortunately, the authors do not present the total LRF rate of their cohort, including patients who develop distant metastases. This is important, given that the success of any local tumor therapy has to be judged foremost on locoregional tumor control in all treated patients. Second, why were only 12 of 27 patients with LRF eligible for salvage chemoradiotherapy? Did regional failure in the remaining 15 patients occur within the previous field of radiation? In this context, it is of utmost interest to see whether LRF is associated with any of the (potential) risk factors for local recurrence: resection status, type of operation and extent of lymphadenectomy, lymphovascular invasion, regression to preoperative radiochemotherapy, and completeness of chemotherapy and/or radiotherapy. Third, the authors interpret the results of salvage local therapy for LRF only (10 of 27 patients survived 2 years) as unimpressive, most likely because many of these patients developed distant metastases. This raises the question of whether a second local therapy is really adequate for these patients who already had local TMT, and whether these patients would do better with (additional) systemic therapy. The high rate of distant metastases in the entire cohort (36%) also implies that systemic disease control, in particular, needs to be optimized. Fourth, the authors question the effectiveness of extensive surveillance strategies, especially periodic endoscopies, given that lumenonly LRF was only observed in 11 of 518 patients. Again, to adequately judge on this subject, the authors should provide data on the total number of luminal recurrences, including patients with metastases. Moreover, it would be interesting to know how many LRFs were diagnosed in asymptomatic patients during routine surveillance and how many LRFs were observed in symptomatic patients who presented outside of routine surveillance. Finally, in our view, postoperative surveillance should not only be usedtodetectandpotentiallytreatrecurrentorprogressivediseaseasearly aspossible.Surveillancestrategies shouldalsoaimtorecognizeandrelieve functional disorders, alimentary deficits, and psychological problems. And although surveillance visits may indeed create stress and anxiety for some patients, we experience mostly the opposite in clinical practice: many patients ask for systematic surveillance and report that it makes them feel cared for and gives them a sense of security.