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Ann Thorac Surg 2005;80:1183-1184
© 2005 The Society of Thoracic Surgeons

Original article: General thoracic

Invited commentary

Jeffrey M. Piehler, MD

Department of Cardiothoracic Surgery, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160

(Email: jpiehler@kumc.edu).

The first 20% of the full text of this article appears below.

Esophageal cancer remains highly lethal, with surgical resection generally offering benefit to only small subsets of patients, usually those with fortuitously discovered early stage disease. Perhaps as a consequence of resultant therapeutic frustration, thoracic surgeons have widely accepted a management strategy incorporating induction chemotherapy or chemoradiation prior to resection despite the absence of convincing supportive data that such is preferable to surgery alone. One is forced to rely on analyses or meta-analyses of single institution experiences, usually based on historical controls, or to creatively dissect the data in the few available phase III studies to generate any conviction of benefit. Nevertheless, fueled by the documented benefits of such preoperative therapy in other venues, such as bronchogenic carcinoma, there is sufficient consensus of benefit that randomized trials addressing the subject have been abandoned due to the unattractiveness of the control arm. Therefore the prevailing standard practice (including at this surgeon's institution) is that induction therapy is offered to almost all patients with potentially resectable disease beyond superficial invasion. Despite this tenuous foundation, the debate has largely moved beyond the question of the benefit of induction therapy and is now focusing on relative effectiveness of the virtually limitless permutations and combinations of chemotherapy and radiation therapy that can be administered prior to resection.

Alas, such is not totally irrational. Numerous . . . [Full Text of this Article]






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