Comparison of Outcome of Esophagectomy Versus Nonsurgical Treatment for Resectable Esophageal Cancer with Clinical Complete Response to Neoadjuvant Therapy

Yu Ohkura, Junichi Shindoh, Masaki Ueno, Toshiro Iizuka, Harushi Udagawa

Treatment for patients who have achieved clinical complete response (cCR) after neoadjuvant therapy has not been established, and there is no consensus regarding the indications for either esophagectomy or nonsurgical treatment. Among 1,545 patients with esophageal cancer at Toranomon Hospital between January 2006 and August 2017, 39 who achieved cCR after neoadjuvant treatment were divided into two groups according to treatment: esophagectomy group (n = 18) and nonsurgical treatment group (n = 21) for comparison. No significant intergroup difference was observed in baseline characteristics. Pathological complete response was confirmed in 13 (72.2%) of the 18 patients who underwent esophagectomy, whereas residual tumor was detected at the location of primary tumor in 2 (11.1%) patients, and lymph node metastasis was found in 3 (16.7%) patients. Recurrence-free survival (RFS) was significantly longer in the esophagectomy group than in the nonsurgical group (p = 0.002). Disease-specific survival (DSS) was significantly longer in the esophagectomy group (p = 0.007). However, no significant intergroup difference was observed in overall survival estimated based on all deaths, including respiratory failure and aspiration pneumonia (p = 0.451). With improved diagnostic accuracy, nonsurgical treatment can be an option for patients estimated as cCR after treatment administered in a neoadjuvant setting. However, surgical resection is considered more appropriate because of residual tumor in some patients with cCR and because of superior DSS and RFS following esophagectomy compared with nonsurgical treatment. Future studies must focus on ameliorating late postoperative complications, such as respiratory failure and aspiration pneumonia.