[Surgery after upfront radiochemotherapy for locally advanced esophageal cancer: To do or not to do?]

The treatment of locally advanced esophageal cancer is still evolving. Surgery was considered as the backbone of the therapeutic management for a long time. Nowadays, chemoradiation has taken a major place in the neoadjuvant setting or as an exclusive treatment. Although some patients benefit from esophagectomy after chemoradiotherapy, a large subset of patients has no benefit and morbi-mortality rates are increased with a trimodality strategy. Patients who will have a local failure are at high risk of distant metastases in the follow-up. A third group of patients will have persistent locoregional disease after chemoradiotherapy and may benefit from surgery, but only a minority of patients with locally advanced disease are eligible. The impact of surgery after upfront chemoradiotherapy on survival and the quality of life of patients with locally advanced squamous cell esophageal cancer remain uncertain. An active surveillance strategy after chemoradiation or salvage esophagectomy for a locally residual disease might improve the prognosis of these patients. An optimized bimodality such as chemoradiotherapy delivering at least 50Gy is still standard and salvage surgery for local persistent disease or a local failure must be discussed in the framework of a multidisciplinary group for selected patients only.