Should cT2 esophageal cancer get neoadjuvant treatment before surgery?

In recent years treatment options for esophageal cancer were expanding as randomized trials have shown a beneficial effect of preoperative chemotherapy and of chemoradiotherapy (1-7). However, it is unclear whether early stage cancers also benefit from preoperative therapy since the number of patients included in such randomized trials is small (8-10). In a more recently published randomized trial, Mariette et al. (11) investigated the benefit of preoperative chemoradiotherapy in stage I and II esophageal carcinomas. A total of 195 patients were randomized between primary surgery and preoperative chemoradiotherapy (cisplatin/5- FU +45 Gy), followed by surgery. Despite of a significant downstaging and a pathologic complete remission (pCR) in 33.3% of cases in the chemoradiotherapy group, no improvement of neither R0 resection rate nor overall survival were observed. Moreover, there was no difference in postoperative complications but there was an increase in hospital mortality in the chemoradiotherapy group (11.1% vs. 3.4%), which may have affected the overall outcome of the trial. Due to these results neoadjuvant treatment for T2 esophageal cancer remains highly controversial.