When to resect following neoadjuvant therapy for esophageal cancer—issues and limitations in addressing this decision

In this issue of the European Journal of Cardio-Thoracic Surgery, Ranney et al. address the very pressing and often debated issue of the timing of esophagectomy following neoadjuvant chemoradiation (nCRT) for patients with esophageal adenocarcinoma (1). As the authors highlight, this question has persisted among those who treat esophageal cancer. Its importance lies in the balance of choosing the optimal time frame after nCRT. On the one hand, increasing the time to surgery can lead to superior pathologic responses (2,3). On the other, a prolonged period after nCRT can make surgical resection more technically challenging as the effects of radiation accumulate, and studies (including this one) have shown that overall survival (OS) may be more inferior the longer one waits to resect (4,5). Still other studies have reported no association between timing of resection and outcomes, further complicating this issue (6,7).