Neoadjuvant Therapy in Esophageal Cancer: Is Surgery Always Necessary After a Complete Response?
Keywords:
esophageal cancer; neoadjuvant therapy; complete pathological response; esophagectomy; surveillanceAbstract
Introduction: In resectable esophageal cancer, neoadjuvant therapy followed by esophagectomy is the standard of care, as it has been shown to improve survival compared to surgery alone. The increase in complete responses following chemoradiotherapy raises the possibility of deferring surgery in selected patients.
Objective: To analyze the available evidence on neoadjuvant therapy in resectable esophageal cancer, its complete response rates, and the implications of follow-up via active surveillance versus esophagectomy, with an evaluation of benefits and risks.
Methods: A narrative review of the literature was conducted through September 2025, including clinical trials, cohort studies, systematic reviews, and guidelines on chemoradiotherapy, complete response, surveillance, and deferred surgery. Findings from recent multicenter studies and recommendations from international societies were also incorporated.
Results: Consolidated evidence from randomized clinical trials of chemoradiotherapy for esophageal cancer followed by surgery and long-term follow-up confirms that the combination of chemoradiotherapy and surgery improves overall survival and the rate of complete resections. Between 20% and 40% of patients achieve a pathological complete response, which is associated with a better prognosis. Diagnostic techniques to confirm complete response have limitations, and the risk of occult recurrence persists. Recent studies, including trials of surgery as needed for esophageal cancer, suggest that active surveillance may offer comparable survival in selected patients, provided that intensive follow-up is ensured.
Conclusions: Chemoradiotherapy followed by esophagectomy remains the standard of care. Surveillance after complete response is a promising but still experimental option that should be reserved for research protocols or for high-risk patients.
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