Surveillance for Esophageal Cancer from SANO Trial

Surveillance for esophageal cancer, particularly in the context of patients treated with neoadjuvant chemoradiotherapy (nCRT), is a critical area of research and clinical practice. Active surveillance is an approach where patients are closely monitored after nCRT instead of proceeding directly to surgery. This strategy has been shown to be non-inferior to immediate surgery for select patients, but it comes with challenges, especially in identifying which patients are suitable for this approach.

The SANO trial analyzed 750 esophageal or junctional cancer patients treated with the CROSS regimen of nCRT. It found that only 37% achieved a complete clinical response (CCR) 12 weeks after treatment, and of those who entered active surveillance (198 patients), only 25% maintained sustained CCR over a median follow-up of 54 months. This highlights the limited success of achieving and maintaining full remission with active surveillance.

Key findings from the study include:

• Patients with higher clinical nodal categories (cN2–3) had lower odds of achieving CCR and a twofold higher risk of recurrence, making them less suitable for active surveillance.
• Tumor histology influenced outcomes, with squamous cell carcinoma showing better distant progression-free survival compared to adenocarcinoma.
• Standard clinical factors like age, sex, tumor differentiation, and tumor size were not reliable predictors of CCR or sustained CCR.
• Current diagnostic tools, such as PET-CT and endoscopic ultrasound, have limited accuracy in detecting residual disease.

The study underscores the need for advanced biomarkers, such as radiomics, circulating tumor DNA (ctDNA), and FAPI PET-CT, to improve the prediction of treatment response and guide decisions about active surveillance versus surgery. This approach could help optimize treatment strategies and reduce unnecessary delays for high-risk patients.