RENAISSANCE trial does not support routine surgery for oligometastatic gastro-oesophageal cancer

The commentary assesses whether response to initial systemic therapy justifies surgery for selected patients with advanced gastro-oesophageal adenocarcinoma. In the phase III RENAISSANCE trial, patients whose disease had not progressed after four cycles of fluorouracil, leucovorin, oxaliplatin and docetaxel (FLOT) were randomized to surgery followed by further FLOT or continued systemic therapy alone. The intention-to-treat population included 139 patients.

The primary overall-survival endpoint was not met (hazard ratio 1.04, 95% CI 0.69–1.56; P=0.86). The commentary notes that reported median survival values were 18.5 months with surgery and 23.6 months with systemic therapy alone, correcting an order reversal in a cited review. Ninety-day postoperative mortality was 8%. At least four further chemotherapy cycles were received by 42% of patients assigned to surgery, compared with 71% assigned to systemic therapy alone.

The author argues that non-progression after induction therapy does not establish that surgery improves survival, and that perioperative harms may affect both survival and delivery of systemic treatment. A subgroup with retroperitoneal nodal metastases only had median survival of 30 versus 17 months, but represented 20% of the trial population. The commentary supports further prospective study of narrower selection criteria; these findings do not establish a survival benefit for response-selected patients in routine practice.