Isolated local recurrence or solitary solid organ metastasis after esophagectomy for cancer is not the end of the road

Abstract

Recurrent disease after esophagectomy bears an infaust prognosis, especially when multiple recurrences are present. But little is known about survival in patients with limited recurrence (solitary locoregional recurrence or solid organ metastasis). Herein, we report our experience with these subgroups. We analyzed 1754 consecutive patients surgically treated with curative resection for esophageal cancer and cancer of the gastroesophageal junction between 1990 and 2012. Seven subgroups were defined according to the recurrence type (locoregional vs. organ metastasis), the site of recurrence (abdominal, thoracic, cervical for lymph nodes and lung, liver, adrenals and others for organ metastasis) and also the number of lesions (one vs. multiple lymph node stations or organ metastasis) Of these groups; clinical isolated locoregional recurrence (ciLR) was defined as solitary lymph-node recurrence confined to one compartment (cervical, thoracic or abdominal, within or outside surgical dissection-field) at clinical staging. Clinical solitary solid organ metastasis (csSOM) was defined as metastasis in a resectable solid organ, i.e. liver, lung, brain or adrenal. Salvage therapies were grouped in five categories. Kaplan-Meier curves were used to calculate survival. Recurrent disease was observed in 766 patients (43.7%) with overall 5-year survival of 4.5% after diagnosis of recurrence. Fifty-seven patients (7.4%) showed ciLR and 110 (14.4%) csSOM. Median time-to-recurrence was 16.8 months in ciLR and 9.9 months in csSOM (P = 0.0074). Survival is significantly improved compared to supportive therapy when local therapy is possible (P < 0.0001). In 25 (15%) of ciLR or csSOM patients, surgical therapy with or without systemic therapy, yielded a 5-year survival of 49.9% (median 54.8 months) after diagnosis of recurrence. When surgery was impossible or contraindicated, the combination of chemoradiotherapy appeared to be superior to chemotherapy alone (respectively 27.0% vs. 4.6% 5-year survival) or radiotherapy alone (no 5-year survival). Recurrent disease after esophagectomy is a common problem with poor overall survival. However prolonged survival could be obtained in selected patients if the recurrent disease is limited to ciLR or csSOM, if surgery (+/- systemic therapy) can be performed. If not a combination of chemoradiotherapy seems to offer the second best option. Patients presenting with a ciLR or csSOM should be discussed in a dedicated multidisciplinary team meeting as to evaluate and define the place of salvage treatment which in well selected cases could offer a perspective of prolonged survival.

The role of surgical treatment in isolated organ recurrence of esophageal cancer—a systematic review of the literature

“…The surgery group showed a more favorable prognosis in terms of both survival after esophagectomy and survival after initial recurrence [ 10 ]. The largest retrospective study comparing different treatment options for different subtypes of recurrence of esophageal cancer following curative surgical resection (anastomotic, locoregional, single solid organ metastasis, single metastasis at another location, multiple hematogenic metastasis, or mixed-type recurrence) has been conducted by Depypere et al Regarding the subgroup of patients with single solid organ metastasis (liver, brain, lung, and adrenal), the authors found that the surgically treated patients, with or without systematic chemotherapy ( n = 20), had a significantly better survival in comparison with the non-surgically treated patients ( n = 63), with a median survival after diagnosis of recurrence of 54.8 months (5-year survival of 43.9%) and 11.6 months (5-year survival of 4.6%), respectively ( p = 0.0004) [ 41 ]. However, in comparative studies, various prognostic variables are unevenly distributed among the surgical and non-surgical groups.…”

Rapid progression of a granulocyte colony-stimulating factor-producing liver tumor metastasized from esophagogastric junction cancer: A case report and literature review

“…Little is known about surgical indications for patients with EGJ cancer who undergo surgery for the primary lesion and experience recurrence. Depypere et al (32), analyzed 1754 patients surgically treated with curative resection for esophageal cancer and EGJ cancer and reported a 49.9% 5-year overall survival rate in patients who underwent surgical resection of isolated local recurrence or solitary solid organ metastasis with or without systemic therapy. However, a multidisciplinary team is needed for the optimal management of the recurrence of EGJ cancer, and surgery should be limited to selected patients, especially when considering the surgical indication for patients with G-CSF-producing EGJ cancer given its rapid progression and unfavorable prognosis.…”

The Role of Tumor Microenvironment in Chemoresistance: 3D Extracellular Matrices as Accomplices

“…Although promising progress has been attained in treating esophageal cancer, it responds poorly to chemotherapeutic drugs and the mortality still remains high [ 51 , 55 , 56 , 57 , 58 , 59 ]. Surgery, chemotherapy and radiotherapy are the most widely-used treatment methods but about half of advanced esophageal cancer cases result in recurrence and patients normally succumb to resistant disease [ 60 , 61 , 62 , 63 , 64 ]. There is a lack of understanding of the mechanisms driving the initiation, progression and the occurrence of refractory disease.…”