Response to the Comment on “Active Surveillance Versus Immediate Surgery in Clinically Complete Responders After Neoadjuvant Chemoradiotherapy for Esophageal Cancer”

Wilk, Berend J van der; Lanschot, J. Jan B. van

doi:10.1097/sla.0000000000003861

Cited by 11 publications

(14 citation statements)

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“…Whether or not surgery is needed after clinical and radiographic response to NT has also been explored in esophageal and breast cancer. 20,21 Although the true proportion of melanoma patients who may have clinical radiographic response after NT is unknown and may depend on the regimen, strategies such as placing a marker before therapy may be considered such that repeat sampling with limited surgery or biopsy to confirm pCR can be performed. However for patients with metastatic melanoma and complete clinical and radiographic response, biopsy of prior sites of disease is not routinely performed.…”

Section: Discussionmentioning

confidence: 99%

Multicenter Experience with Neoadjuvant Therapy in Melanoma Highlights Heterogeneity in Contemporary Practice

et al. 2022

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Objective: To determine the feasibility and impact of neoadjuvant therapy (NT) in patients who present with advanced melanoma amenable to surgical resection. Summary Background Data: Given current effective systemic therapy for melanoma, the use of NT is being explored in patients with advanced melanoma with disease amenable to surgical resection. Methods: Prospective data from 3 institutions was obtained in patients with clinically evident Stage III/IV melanoma who underwent NT. The primary objective was to compare recurrence-free survival between patients who had pathologic complete response (pCR) to those with persistent disease. Results: NT was offered to 45 patients, with 43 patients initiating various NT regimens including PD-1 antagonist (PD-1) therapy (N = 16), PD-1 plus ipilimumab (N = 10), BRAF/MEK inhibitor therapy (N = 14), a combination of those three (N = 1), and talimogene laherparepvec (TVEC) (N = 2). Thirty-two (74.1%) patients underwent surgery whereas 11 patients did not undergo surgery for these reasons: clinical CR (N = 7), progressive disease not amenable to resection (N = 3), and ongoing therapy (N = 1). 12 of 32 patients (37.5%) had pCR with these therapies: PD-1 (N = 4), PD-1 plus ipilimumab (N = 2), BRAF/MEK (N = 4), combination (N = 1), and TVEC (N = 1). At median followup of 16.4 months there was only 1 recurrence in the pCR group and patients with a pCR had significantly improved recurrence-free survival compared to patients without pCR (p = 0.004). Conclusions: Despite variability in NT regimens across institutions, NT for melanoma is feasible and associated with improved prognosis in patients who achieve a pCR. Maximizing rates of pCR could improve prognosis for patients with advanced melanoma.

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Section: Discussionmentioning

confidence: 99%

Multicenter Experience with Neoadjuvant Therapy in Melanoma Highlights Heterogeneity in Contemporary Practice

et al. 2022

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“…Consistent with the results of complete RCTs, retrospective cohort studies have shown the feasibility and non-inferiority of a non-surgical approach strategy in patients without compromising OS rates [71,72]. Van der Wilk et al reported that patients with cCR undergoing active surveillance or surgery on principle had a 3-year OS of 77% and 55%, respectively (HR 0.41; 95% CI 0.14-1.20, p = 0.104), and an equal distant dissemination rate (28%) [73]. Similar results regarding the median OS in the active surveillance group versus surgery on principle are reported by Furlong et In conclusion, post-nCRT surveillance and surgery as needed are feasible for patients who reach cCRs without compromising OS.…”

Section: Active Surveillance In Patient Post-ncrt With Complete Responsementioning

confidence: 99%

Recent Progress in the Neoadjuvant Treatment Strategy for Locally Advanced Esophageal Cancer

Hou

Pan

Hao

et al. 2021

Cancers

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Neoadjuvant therapies, primarily chemotherapy and chemoradiotherapy, are able to improve the overall survival (OS) in patients with locally advanced resectable esophageal cancer (EC) based on the results of several randomized clinical trials. The advantage of neoadjuvant therapy is chiefly attributed to the decreased risk of local–regional recurrence and distant metastasis. Thus, it has been recommended as standard treatment for patients with resectable EC. However, several fundamental problems remain. First, the combination of neoadjuvant chemotherapy (nCT), neoadjuvant chemoradiotherapy (nCRT), and surgery for EC patients with different histological types remains controversial. Furthermore, to reduce the toxicity of preoperative chemotherapy and the risk of complications caused by preoperative radiation therapy, the treatment protocols of nCT and nCRT still need to be investigated and optimized by prospective trials. Moreover, for patients with complete clinical response following neoadjuvant therapy, it is worth ascertaining whether a “watch and wait” surveillance plus surgery-as-needed policy is more favorable, as well as, in addition to preoperative chemoradiotherapy, whether immunotherapy, especially when combined with the traditional neoadjuvant therapy regimens, brings new prospects for EC treatment. In this review, we summarize the recent insights into the research progress and existing problems of neoadjuvant therapy for locally advanced resectable EC.

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“…In further detail, during CRE-I 6 weeks after completion of induction CRT (CROSS), all patients All patients with residual disease morbidity 60% mortality 3%-5% pR0 90%-100% TA B L E 1 Differences between definitive chemoradiation with salvage surgery and neoadjuvant chemoradiation with delayed surgery (surgery as needed) undergo esophagoduodenoscopy with biopsies, radial EUS with additional EUS-FNA in case of suspected lymph node disease, and PET-CT for exclusion of distant metastases. 46 CRE-II is performed 12 weeks after completion of CRT including 18F-FDG-PET-CT, followed by endoscopy with bite-on-bite biopsies and ultra-endosonography plus fine needle aspiration of suspected lymph nodes and/or PET-positive lesions. Complete responders are then encountered in the active surveillance therapeutic arm and are scheduled to undergo intense CREs (PET-CT, bite-on-bite biopsies, EUS-FNA) every 3 months during the first year, every 4 months during the second year, twice a year for the third year and annually for the fourth and fifth years.…”

Section: R Andomized Clini C Al S Tud Ie Smentioning

confidence: 99%

“…A Dutch multicenter study of 31 patients under active surveillance with surgery as needed and 67 patients in the immediate surgery group after nCRT (CROSS regimen) showed that 3‐year overall survival was 77% and 55%, respectively (HR 0.41; 95% CI 0.14‐1.20, P = .104) 46 . Moreover, the 3‐year progression‐free survival was 60% and 54%, respectively (HR 1.08; 95% CI 0.44‐2.67, P = .871).…”

Section: Retrospective Studies On the Efficacy Of Active Surveillance...mentioning

confidence: 99%

“…In the intervention arm (active surveillance), patients with a cCR 12 weeks after nCRT will undergo intense follow‐up (CREs) and (delayed) surgery is only done when there is a strong suspicion of cancer recurrence without distant metastases. In further detail, during CRE‐I 6 weeks after completion of induction CRT (CROSS), all patients undergo esophagoduodenoscopy with biopsies, radial EUS with additional EUS‐FNA in case of suspected lymph node disease, and PET‐CT for exclusion of distant metastases 46 . CRE‐II is performed 12 weeks after completion of CRT including 18F–FDG‐PET‐CT, followed by endoscopy with bite‐on‐bite biopsies and ultra‐endosonography plus fine needle aspiration of suspected lymph nodes and/or PET‐positive lesions.…”

Section: Randomized Clinical Studiesmentioning

confidence: 99%

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Multidisciplinary treatment of esophageal cancer: The role of active surveillance after neoadjuvant chemoradiation

Triantafyllou

Wijnhoven

2020

Annals of Gastroent Surgery

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Esophageal cancer (EC) is an aggressive disease. The two most common types of EC are adenocarcinoma (AC) and squamous cell carcinoma (SCC). AC and SCC differ with regard to etiology, geographic distribution, response to chemotherapy/ radiotherapy, prognosis and possibly need for surgical resection. Esophagectomy is the cornerstone in the treatment of EC. During the last two decades, studies on the lymph node dissection during esophagectomy have shown improved survival in patients who underwent an extensive nodal dissection. 1 A total number of 23 lymph nodes were proposed as the optimal threshold in order to achieve a maximal survival benefit after esophagectomy. The extent of lymph node dissection expressed as the total number of nodes dissected was found to be an independent predictor of survival. 2 Whether the observed relationship between the number of nodes dissected and survival reflects a true benefit of more extensive surgery or is due to stage migration, is not clear yet. However, a transthoracic esophagectomy with a two-field nodal dissection is considered by many as the standard surgical approach nowadays. Esophagectomy is associated with major complications. 3-4 The diminished quality of life of patients after neoadjuvant therapy plus esophagectomy is another drawback. A patient's quality of life is substantially impaired after surgery including role and social functioning. 5 Reducing morbidity after esophagectomy is a challenge. The application of minimally invasive surgical techniques, better selection of surgical candidates, preoptimization of patient condition, and enhanced recovery protocols have shown to be associated with a reduction in complications and quicker return to normal functioning. 6-10

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Response to the Comment on “Active Surveillance Versus Immediate Surgery in Clinically Complete Responders After Neoadjuvant Chemoradiotherapy for Esophageal Cancer”

Abstract: The authors comment on the pathologically complete response (pCR) rate of 24% for the matched group of patients undergoing immediate surgery. As reported in the discussion section of the paper, a considerable number of patients having pCR were excluded due to propensity-score matching.

Cited by 11 publications

References 9 publications

Multicenter Experience with Neoadjuvant Therapy in Melanoma Highlights Heterogeneity in Contemporary Practice

Multicenter Experience with Neoadjuvant Therapy in Melanoma Highlights Heterogeneity in Contemporary Practice

Recent Progress in the Neoadjuvant Treatment Strategy for Locally Advanced Esophageal Cancer

Multidisciplinary treatment of esophageal cancer: The role of active surveillance after neoadjuvant chemoradiation

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