Surgery in the era of neoadjuvant therapy for cancer of the esophagus

Multimodality treatment strategies have become commonplace and stand-of-care in the management of esophageal cancer. In Japan, preoperative chemotherapy is routine, while in many centers around the globe chemoradiotherapy is widely practiced. How surgery should be integrated and the manner in which esophagectomy should be carried out remain controversial. From the literature, it seems that esophagectomy for salvage after definitive chemoradiotherapy is associated with increased morbidity rates. In the neoadjuvant setting, however, where less chemotherapy and lower dose of radiotherapy is usually given, results are comparable with upfront surgery. Video-assisted thoracoscopic esophagectomy is also safe after neoadjuvant therapy; special adjunct like recurrent laryngeal nerve monitoring may be helpful for extended mediastinal lymphadenectomy. There is not enough evidence to suggest that lesser degree of lymphadenectomy is required after neoadjuvant therapy. As such the same degree of nodal dissection is recommended. Further work is required to delineate the role of surgery in multimodality treatment programs.