A surveillance strategy for patients with esophageal adenocarcinoma treated with chemoradiation and surgery (trimodality therapy) can potentially be customized based on surgical pathology stage, according to an analysis of 518 patients with esophageal adenocarcinoma who underwent trimodality therapy at The University of Texas MD Anderson Cancer Center in Houston and were frequently surveyed. “The compelling data show an excellent association between surgical pathology stage and frequency/type/timing of relapses after trimodality therapy in patients with esophageal adenocarcinoma, Takashi Taketa, MD, and colleagues at MD Anderson wrote in the Journal of the National Comprehensive Cancer Network.
All patients in the study had preoperative chemoradiation with intravenous or oral fluoropyrimidine with either a platinum compound or a taxane and a median total radiation dose of 50.4 Gy (range, 39.6–64.8 Gy) in daily fractions of 1.8 Gy. The median age of patients was 61 years (range 23–79 years) and most had clinical stage II (39%) or III (51.7%) cancer. The median follow-up time after esophageal surgery was 55.4 months, and disease relapse occurred in 215 patients (41.5%).
“The higher the [surgical pathology stage], reflecting the resistance of the primary tumor to chemoradiation, the higher the metastatic potential of esophageal adenocarcinoma. The present data show that distant metastases are much more frequent than locoregional-only relapses and that a higher [surgical pathology stage] leads to higher rates of relapses,” the investigators reported.
“In addition, patients with a higher [surgical pathology stage] tend to develop metastases not only more frequently but also sooner than those with a lower [surgical pathology stage].” In the first 12 months after surgery, the fraction of all relapses in various surgical pathology stage categories were as follows: stage 0 = 41%, I = 42%, II = 61%, and III = 68%.
The authors proposed that “the frequency of relapses based on timing could be exploited in formulating future surveillance strategies.” For example, since almost all relapses among patients with surgical pathology stages 0 and I occurred within 36 months of surgery, surveillance might be terminated in these patients after 3 years.
“The quandary is whether it is reasonable to recommend any surveillance (and what the frequency should be and what tests should be performed) for [surgical pathology stage] II or III. Based on the present data,” the authors stated, “one could question the benefit of surveillance in patients with [surgical pathology stage] III, because approximately 60% of patients are likely to experience relapse and 86% of these relapses are anticipated to be metastatic. Considerable discussion would be necessary to establish guidance for patients with [surgical pathology stage] II.”
The authors called for “a serious national dialogue … to restructure the overall surveillance strategy for [esophageal adenocarcinoma] (and this can be extended to a few other solid tumors). Such a dialogue may lead to the launch of a prospective trial to establish a firm evidence-based strategy.” ■
Taketa T, et al: J Natl Compr Canc Netw 12:1139-1144, 2014.