Actionable Locoregional Relapses after Therapy of Localized Esophageal Cancer: Insights from a Large Cohort

Abstract

Objective: The goal of surveillance after therapy of localized esophageal cancer (LEC) is to identify actionable relapses amenable to salvage; however, the current surveillance algorithms are not optimized. We report on a large cohort of LEC patients with actionable locoregional relapses (LRRs). Methods: Between 2000 and 2013, 127 (denominator = 752) patients with actionable LRR were identified. Histologic/cytologic confirmation was the gold standard. All surveillance tools (imaging, endoscopy, fine needle aspiration) were assessed. Results: Most patients were men (89%), had adenocarcinoma (79%), and had no new symptoms (72%) when diagnosed with LRR. In trimodality patients, endoscopic confirmation of positron emission tomography-computed tomography-suspected LRR occurred in only 44%, and 56% required additional tools (e.g., fine needle aspiration). Alternatively, in bimodality patients, endoscopy confirmed LRRs in 81%. Trimodality patients had a higher risk of subsequent LRR/distant metastases after the first LRR than the bimodality patients (p = 0.03). In all patients, 78% of the subsequent relapses were distant. For patients who were salvaged, survival was significantly prolonged (50.6 vs. 25.1 months, p < 0.01). Conclusions: Patients live longer after successful salvage of the LRR than if salvage is not possible. After LRR, patients have a high risk of subsequent distant metastasis and whether the second relapse is local or distant, survival is uniformly poor.

Change in stage after neoadjuvant chemoradiation is associated with survival in patients with esophageal cancer

“…Given worsened outcomes in patients with incomplete pathologic responses, there is a pressing need to identify nonresponders early, potentially changing therapies via a personalized approach. The optimal diagnostic method of predicting pCR in esophageal cancer has not been established, although the use of interim fluorine‐18 ( 18 F) fluorodeoxyglucose (FDG) positron emission tomography‐computed tomography is promising 23,24 . Though treatment response is likely dictated by intrinsic tumor biology primarily, little is known about the molecular mechanisms that predict the response of esophageal cancers to CRT.…”

“…Current research demonstrates that genetic polymorphisms can predict response to neoadjuvant CRT, particularly mutations among the ERCC1 and XRCC1 genes that play a role in DNA repair 25–28 . While the poor response to initial therapy may suggest tumor resistance to conventional therapies, studies have shown that salvage therapy with radiation or CRT can improve survival in esophageal cancer patients with recurrent disease 23,29,30 . Future studies should investigate if patients with incomplete tumor response would benefit from altering therapy and if these patients can be identified before completion of trimodality therapy to change the approach early and improve outcomes.…”