食管鳞状细胞癌临床完全缓解后能否安全避免食管切除术？免疫治疗时代的疗效评估、主动监测与挽救治疗。
完整摘要 · 中文译文
综述目的：在食管鳞状细胞癌（ESCC）中，放化疗或含免疫治疗的新辅助治疗后达到临床完全缓解（cCR）的情况日益增多。我们探讨在部分完全缓解者中是否可以安全地推迟或避免食管切除术，并将病理完全缓解（pCR）的预测与豁免手术所需的更高置信度加以区分。 近期发现：III期SANO试验显示，在新辅助放化疗后达到cCR的患者中，与标准手术相比，主动监测的2年总生存非劣效，且早期生活质量获益；然而，约四分之三的参与者为腺癌。ESCC特异性的preSINO研究显示，咬取式活检、超声内镜联合细针穿刺抽吸以及PET/CT可减少但并不能消除遗漏的残留病变。在preSINO中嵌套开展的一项生物标志物分析中，将肿瘤信息导向的循环肿瘤DNA（ctDNA）加入常规评估，使非pCR的敏感性提高至约92-93%；这并非独立验证。新辅助免疫治疗，包括ESCORT-NEO和PALACE方案，提高了pCR率，但应答评估的准确性尚未在这些治疗背景下得到验证。早期ESCC根治性放化疗联合选择性挽救治疗的试验在概念上确立了器官保留；现代的问题是在严格定义的cCR之后监测是否可以个体化。cCR后的主动监测现已成为结构化项目内一种可信的选择， 但在食管鳞状细胞癌（ESCC）中常规省略食管切除术尚非标准治疗。器官保留应被视为一项纵向的残留病灶排除计划，具有预设的挽救触发条件，而非一次性宣告临床完全缓解（cCR）。在免疫治疗相关的cCR能够常规支持非手术治疗之前，需要开展针对ESCC、针对治疗情境的临床试验，整合标准化的内镜和淋巴结评估、PET/CT、系列ctDNA以及挽救治疗结局。
完整摘要 · 英文原文
PURPOSE OF REVIEW: Clinical complete response (cCR) after chemoradiotherapy or immunotherapy-containing neoadjuvant treatment is increasingly encountered in esophageal squamous cell carcinoma (ESCC). We examine whether esophagectomy can be safely deferred or avoided in selected complete responders, distinguishing prediction of pathologic complete response (pCR) from the higher confidence required to omit surgery. RECENT FINDINGS: The phase III SANO trial showed non-inferior 2-year overall survival with active surveillance versus standard surgery after cCR following neoadjuvant chemoradiotherapy, with early quality-of-life benefits; however, approximately three quarters of participants had adenocarcinoma. The ESCC-specific preSINO study showed that bite-on-bite biopsies, endoscopic ultrasonography with fine-needle aspiration, and PET/CT reduce but do not eliminate missed residual disease. In a biomarker analysis nested within preSINO, adding tumor-informed circulating tumor DNA (ctDNA) to conventional evaluation increased sensitivity for non-pCR to approximately 92-93%; this is not independent validation. Neoadjuvant immunotherapy, including ESCORT-NEO and PALACE regimens, has increased pCR rates, but response-assessment accuracy has not been validated in these treatment contexts. Earlier ESCC trials of definitive chemoradiotherapy with selective salvage established organ preservation conceptually; the modern question is whether surveillance can be individualized after rigorously defined cCR. Active surveillance after cCR is now a credible option within structured programs, but routine omission of esophagectomy in ESCC is not yet standard care. Organ preservation should be viewed as a longitudinal residual-disease exclusion program with predefined rescue triggers rather than a one-time declaration of cCR. ESCC-specific, treatment-context-specific trials integrating standardized endoscopic and nodal assessment, PET/CT, serial ctDNA, and salvage outcomes are needed before immunotherapy-associated cCR can routinely justify nonoperative management.