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J Thorac Cardiovasc Surg 2008;135:1234-1236
© 2008 The American Association for Thoracic Surgery

Invited Commentary

Discussion

Dr Richard I. Whyte (Stanford, Calif). First, I would like to congratulate Dr Rizzetto on a very interesting and well-presented paper that really adds to our knowledge on esophageal cancer, the role of en bloc esophagectomy, and the results of neoadjuvant therapy.

The authors are clearly presenting some very impressive results here in terms of a 70% five-year survival in the 25% of patients who were complete pathologic responders. That is really sort of best in class. Also, they really demonstrate the fact that en bloc resection results in a very low local recurrence rate.

I have 2 or 3 questions, however, and I think Dr DeMeester is going to address those.

First, you have described candidates for neoadjuvant therapy as having locally advanced disease proved by both endoscopic ultrasonographic analysis and PET scans, yet there are no data in the presentation or in the manuscript on the TNM staging of these patients. Can you provide some information as to their pretreatment TNM status?

Dr DeMeester. The problem with pretreatment staging is that the clinical staging for esophageal cancer is terrible. Many of these patients in the earlier time frame did not undergo PET scans or endoscopic ultrasonography. We do that routinely now, and as you know, our preference is primary surgical resection in anyone who we think has limited local regional disease, which for us, is patients who had any depth of tumor with less than 5 obvious nodes determined by means of endoscopic ultrasonographic analysis or PET scan. For anyone with 5 or more nodes, we know that the systemic failure rate with surgical intervention alone in our experience exceeds 80%, and therefore those patients will need chemotherapy either before or after surgical intervention. We talk to the patient about that, and many of these patients . . . [Full Text of this Article]

Related Article

En bloc esophagectomy reduces local recurrence and improves survival compared with transhiatal resection after neoadjuvant therapy for esophageal adenocarcinoma

C. Rizzetto, S.R. DeMeester, J.A. Hagen, C.G. Peyre, J.C. Lipham, and T.R. DeMeester
J. Thorac. Cardiovasc. Surg. 2008 135: 1228-1236. [Abstract] [Full Text] [PDF]