Organ-sparing approach after neoadjuvant treatment in oesophageal cancer

Neoadjuvant chemoradiotherapy (nCRT) or perioperative chemotherapy (pCT) followed by surgical resection is the standard of care for oesophageal and gastroesophageal junction cancer. Up to a third of patients will have a pathological complete response (pCR) to neoadjuvant treatment. Given the significant morbidity associated with surgery, active surveillance is considered as a potential alternative for patients with clinical complete response (cCR) post-nCRT. The preSANO and preSINO trials have validated a multimodal diagnostic strategy combining oesophagogastroduodenoscopy (OGD) with bite-on-bite biopsies, endoscopic ultrasonography (EUS) with fine-needle aspiration of suspicious lymph nodes, and PET-CT to detect residual disease. The SANO trial is assessing whether active surveillance leads to non-inferior overall survival compared to planned surgery. Early results of randomized studies support previous retrospective reports of comparable oncological outcomes, with improved quality of life in the surveillance group. Despite concerns of increased morbidity of postponed surgery upon recurrence, recent data indicate comparable surgical outcomes of delayed oesophagectomy. Ongoing trials, including SANO-2, CELEAC, and NEEDS, aim to rationalize surveillance protocols, while SANO-3 is investigating the role of adding immunotherapy in improving response durability. The evolution and current state of active surveillance approach in oesophageal cancer is discussed in this paper.