Dear editor

We appreciate the valuable comments of Dr. Dimitrios Schizas and colleagues as well as their interest in our manuscript published in July 2016. In their letter, Schizas et al. queried whether T4b esophagogastric cancer invaded the aorta.

In our study, 122 patients (30.5%) were diagnosed with T4 esophagogastric cancer, 17 of which were offered a R1 resection [1]. Unfortunately, in this retrospective multicenter study, we did not collect data concerning adjacent tissues that were invaded. Therefore, we are unable to provide a definitive answer; however, it is the general policy of our hospital to not offer surgery as treatment for T4b with aorta invasion.

As we reported, the 5-year overall survival (OS) rate for patients who underwent a R1 resection was 25.9% (that of patients who underwent a R0 resection was 60.8%). Furthermore, R1 resection was reported to be an independent risk factor for poor OS in patients with pT4 esophageal cancer [2]. Therefore, we are also interested in stent-grafting in patients with T4b esophagogastric cancer that penetrates into the aorta after chemo- or chemoradiotherapy. This novel treatment modality should benefit at least some patients and be less invasive compared to radical esophagectomy combined with descending aorta replacement [3]. However, as Schizas et al. mentioned, the indication of intra-aortic stent-grafting should be carefully discussed because of its high cost and relative invasiveness. For example, patients with multiple lymph node metastases might be excluded from this stent-grafting since the prognosis in patients with T4N3M0 was poor, and the 5-year OS rate of patients diagnosed with T4N3M0 was 21.9% in our study. Rather, intra-aortic stent-grafting would be applicable to patients with T4bN0-2M0.

We again thank Dr. Schizas and colleagues for their interest in this topic. Their new strategy for treating T4b esophagogastric cancer that invades the aorta is attractive given its merits. We hope that a future prospective clinical trial demonstrates the feasibility of their new approach.