Importance of Surveillance and Success of Salvage Strategies After Definitive Chemoradiation in Patients With Esophageal Cancer

Abstract

Purpose Patients with esophageal carcinoma (EC) who are treated with definitive chemoradiotherapy (bimodality therapy [BMT]) experience frequent relapses. In a large cohort, we assessed the timing, frequency, and types of relapses during an aggressive surveillance program and the value of the salvage strategies. Patients and Methods Patients with EC (N = 276) who received BMT were analyzed. Patients who had surgery within 6 months of chemoradiotherapy were excluded to reduce bias. We focused on local relapse (LR) and distant metastases (DM) and the salvage treatment of patients with LR only. Standard statistical methods were applied. Results The median follow-up time was 54.3 months (95% CI, 48.4 to 62.4). First relapses included LR only in 23.2% (n = 64), DM with or without LR in 43.5% (n = 120), and no relapses in 33.3% (n = 92) of patients. Final relapses included no relapses in 33.3%, LR only in 14.5%, DM only in 15.9%, and DM plus LR in 36.2% of patients. Ninety-one percent of LRs occurred within 2 years and 98% occurred within 3 years of BMT. Twenty-three (36%) of 64 patients with LR only underwent salvage surgery, and their median overall survival was 58.6 months (95% CI, 28.8 to not reached) compared with those patients with LR only who were unable to undergo surgery (9.5 months; 95% CI, 7.8 to 13.3). Conclusion Unlike in patients undergoing trimodality therapy, for whom surveillance/salvage treatment plays a lesser role, 1 in the BMT population, approximately 8% of all patients (or 36% of patients with LR only) with LRs occurring more than 6 months after chemoradiotherapy can undergo salvage treatment, and their survival is excellent. Our data support vigilant surveillance, at least in the first 24 months after chemotherapy, in these patients.

Surveillance versus esophagectomy in esophageal cancer patients with a clinical complete response after induction chemoradiation

“…Of the patients who were candidates for salvage esophagectomy, their corresponding survival was quite good: median, 58.6 months; 3-year, 61%; and 5-year, 45%. An impressive 98% of the relapses developed within 3 years, indicating this is the period where regular surveillance is most important if the patient is considered a candidate for additional treatment (31).…”

“…Surveillance strategies differ nationally, with the primary variations found in the frequency of use for PET and endoscopy. To provide a basis for this discussion, an outline of a possible surveillance strategy is provided in Figure 3 that combines recommendations from the existing literature (3,31).…”

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

“…The decision between TMT and BMT is influenced by multiple factors, which have been discussed previously [9-11]. Although it has previously been shown that the locoregional relapse (LRR) rate is low after TMT [12-16], it is considerably higher after BMT [9, 10, 17]. We recently reported that only 2% of 518 patients treated with TMT benefited from surveillance/salvage strategies [12], bringing into question their usefulness in this setting.…”

Esophageal cancer: comparative effectiveness of treatment options

“…Salvage surgery after definitive CRT is appropriate and has good outcomes in responding patients. 74,75 A series of data on nonrandomized patients from the FFCD 9102 trial suggest that attempting surgery after early failure of CRT is beneficial and should be considered in patients who are still operable. 76 A retrospective propensity score-matched study included 65 patients with esophageal AC who underwent salvage esophagectomy after failed definitive CRT and compared this group to 65 matched patients who received planned esophagectomy.…”