Optimal Management of Esophageal Adenocarcinoma: Should We Be CROSS?

Abstract

by Surgery Study (CROSS), and Mamon and Tepper 2 provided an accompanying editorial. CROSS provided definitive evidence of the benefit of preoperative CRT compared with surgery alone for patients with operable esophageal cancer and led to a paradigm shift in practice for many oncologists. 3 However, we question the wisdom of applying these results to all patients with esophageal and junctional cancers, given that the stratified analysis demonstrates a significantly reduced survival advantage for patients with adenocarcinoma compared with squamous cell carcinoma (HR, 0.74 v 0.42). In fact, the benefits of CRT were not statistically significant in either the adenocarcinoma or node-positive subgroups, despite the fact that the vast majority of recruited patients were in these groups. These data suggest that the overall findings of CROSS were strongly driven by the undisputable benefits of CRT in node-negative squamous cell tumors. This argumentisfurtherstrengthenedbythecurrentupdateregardingpatterns of recurrence. ThemultivariableanalysisconfirmsthatthebenefitsofCRTwith respect to local recurrence are markedly greater for patients with squamous cell carcinoma than adenocarcinoma (HR, 0.49; 95% CI, 0.29to0.82).Furthermore,CRTdidnotsignificantlyaffecttheoccurrenceofisolateddistantmetastasesand,incontrasttolocalrecurrence, no breakdown by histologic subtype was provided for distant metastatic disease. We suspect that these distant recurrences may be dominatedbypatientswithadenocarcinoma,inwhichsystemicmetastatic