LAUSR

To the Editor: We read with interest the recently published study ‘‘Active Surveillance Versus Immediate Surgery in Clinically Complete Responders After Neoadjuvant Chemoradiotherapy for Esophageal Cancer.’’ This study suggested that esophagectomy might be safely avoided or postponed until recurrence is found in patients with evidence of complete clinical response (cCR) to neoadjuvant therapy. The premise for this conclusion is that patients designated as having cCR were likely to have pathologic complete response (pCR) were they to undergo esophagectomy and lymph node dissection. The authors used the pre-SANO method of restaging after neoadjuvant therapy that included PET-CT scan, bite-on-bite endoscopic biopsies, and endoscopic ultrasound with FNA of suspicious nodes. These clinical response assessments (CREs) were done at 6 and 12 weeks after the completion of neoadjuvant therapy. Only patients who were free of disease following both CREs were considered to have cCR and formed the basis of this study. From this group of patients with cCR some had ‘‘immediate surgery’’ while others refused surgery and underwent ‘‘active surveillance.’’ First, it is surprising to note that in the patients who had ‘‘immediate surgery’’ the actual pCR rate was only 24%. This is lower than the pCR rate seen in the CROSS trial and other studies. Thus, rather than being a highly selected group of patients with a high likelihood of having pCR, patients in the cCR group in fact had a low likelihood of having pCR after esophagectomy. This suggests that the pre-SANO restaging methodology may be unreliable for selecting patients likely to have true pCR. It also suggests that the majority of patients (76%) in the ‘‘active surveillance’’ group had residual disease and would be expected to show recurrence