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Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA 98111
(Email: gtsdel{at}vmmc.org).
The article by Roedl and colleagues [1] is a critical assessment using positron emission tomography (PET) and PET computed tomographic (CT) scan to quantify treatment response after neoadjuvant chemoradiotherapy, as well as local and systemic recurrence after definitive treatment. Both of these issues are important, and the authors have provided a new technique for gauging response to neoadjuvant therapy. The article suffers from two technical issues. The first being the fact that pathologic response (assessed as less than 10% remaining viable tumor cells) was not done by a designated subset of pathologists. More importantly, the second of three PET assessments, this one examining response of tumor length, was carried at a mean of 14 days after the completion of radiochemotherapy, and as far as we can tell, not specifically correlated with endoscopic findings to assess the presence of esophagitis and ulceration secondary to radiotherapy or reflux disease.
This article is a contribution to answering the three critically important questions regarding combined modality therapy for patients with esophageal malignancy.
Question 1: Can we identify patients who have had complete responses to neoadjuvant therapy and thereby avoid the necessity for surgical resection? This article does not attempt to address this question; however, a very recent publication in The Annals of Thoracic Surgery by McLoughlin and colleagues [2] suggests that even PET negativity after neoadjuvant chemoradiotherapy is not substantially predictive of a complete pathologic response.
Question 2: Can appropriate surgical candidates who are not going to respond to neoadjuvant therapy be identified early and be taken directly to surgical resection? Roedl and colleagues [1] do not address this question specifically, although any system that has the potential for identifying nonresponders would be potentially better used early in therapy rather than simply documenting nonresponse at the completion of neoadjuvant chemoradiotherapy. The question that is most pertinent with respect to the authors' methodology is whether this assessment of tumor length can be carried out with comparable accuracy and improved cost by endoscopy or endoscopic ultrasound rather than PET CTs. Especially in an era of quickly escalating healthcare costs, this question requires further assessment as the authors document "excellent correlation between pre-treatment tumor length measurements with endoscopy and PET CT."
Question 3: What is the most accurate and cost-effective methodology for screening patients after definitive therapy for esophageal cancer? The authors specifically address this question and confirm that PET CT is a more accurate modality than PET alone. The authors point out that patients with recurrent disease can demonstrate responses to subsequent therapy. However, most would agree that the prognosis in these patients is very poor. The assessment of the value of any surveillance technique, especially when the opportunities for successful therapy are modest, should include not only the sensitivity for detecting recurrent disease, but also an analysis of the potential cost and impact of follow-up, or of pathologically verifying all subtle PET abnormalities in patients after definitive therapy for esophageal cancer.
The authors acknowledge that the literature contains significant disagreement regarding the use of PET scanning in the assessment of neoadjuvant treatment response in patients with esophageal cancer. Dr Roedl and colleagues [1] provide pertinent reinforcement that tumor length and its corollary of reduction in tumor length after neoadjuvant therapy are important prognostic indicators. Whether this assessment will ultimately play a significant role in assessing treatment response is unknown. However, continued efforts to definitively address the previously mentioned three questions will remain an important part of ongoing research regarding the treatment of esophageal cancer.
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