Pathological Complete Response after Radio Chemotherapy and Esophagectomy – false Sense of Security?

Abstract Background Esophageal cancer (EC) is associated with a high morbidity and mortality, even in a curative treatment approach. The current standard of care for curative treatment of EC consists of neoadjuvant radio chemotherapy (RCT) followed by resection. Pathological response in the resected tissue is a well-known predictor of disease-free (DFS) and overall survival (OS). Yet, even in a pathological complete response (pCR), cancer recurrence is not infrequent. Aims To analyze DFS and OS in patients with pCR after trimodal therapy and identify risk factors for recurrence. Methods We retrospectively analyzed all patients with pathological complete response after RCT and esophagectomy treated for EC between 01/2014 and 12/2021. Clinical data such as demographic data, tumor characteristics at staging and restaging and postoperative follow-up, were extracted from electronic medical records. Results Of 28 patients, 10 (35.7%) developed cancer recurrence. There were no statistically significant differences in patient or tumor characteristics between patients with or without recurrence. Recurrence occurred after a median 21 months (IQR 30). Median OS was 40.5 months (IQR 40) in patients with and 48.5 months (IQR 32) in patients without recurrence (p=0.121). Recurrence was mostly distant (n = 9, 90%). 4 (of 10, 40%) patients were then addressed in curative, 6 (60%) in palliative intention. Predictive factors for cancer recurrence were persistent tumor in endosonography and/or computed tomography during restaging. Conclusion Even in patients with pCR after RCT and esophagectomy, around one third develops cancer recurrence. A tight follow-up with special attention to distant rather than local recurrence seems beneficial. Patients with an aspect of only partial response at restaging are at higher risk for recurrence and should be monitored even closer.