Locoregional Failure Rate After Preoperative Chemoradiation of Esophageal Adenocarcinoma and the Outcomes of Salvage Strategies

Abstract

A B S T R A C T PurposeThe primary purpose of surveillance of patients with esophageal adenocarcinoma (EAC) and/or esophagogastric junction adenocarcinoma after local therapy (eg, chemoradiotherapy followed by surgery or trimodality therapy [TMT]) is to implement a potentially beneficial salvage therapy to overcome possible morbidity/mortality caused by locoregional failure (LRF). However, the benefits of surveillance are not well understood. We report on LRFs and salvage strategies in a large cohort. Patients and MethodsBetween 2000 and 2010, 518 patients with EAC who completed TMT were analyzed for the frequency of LRF over time and salvage therapy outcomes. Standard statistical techniques were used. ResultsFor 518 patients, the median follow-up time was 29.3 months (range, 1 to 149 months). Distant metastases (with or without LRF) occurred in 188 patients (36%), and LRF only occurred in 27 patients (5%). Eleven of 27 patients had lumen-only LRF. Most LRFs (89%) occurred within 36 months of surgery. Twelve patients had salvage chemoradiotherapy, but only five survived more than 2 years. Four patients needed salvage surgery, and three who survived more than 2 years developed distant metastases. The median overall survival of 27 patients with LRF was 17 months, and 10 patients (37%) survived more than 2 years. Thus, only 2% of all 518 patients benefited from surveillance/salvage strategies. ConclusionOur surveillance strategy, which is representative of many others currently being used, raises doubts about its effectiveness and benefits (along with concerns regarding types and times of studies and costs implications) to patients with EAC who have LRF only after TMT. Fortunately, LRFs are rare after TMT, but the salvage strategies are not highly beneficial. Our data can help develop an evidence-based surveillance strategy.

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

“…16 We previously reported that the rate of LR is low (approximately 5%) after TMT for esophageal and gastroesophageal junction adenocarcinoma. 1 However, the rate of persistent cancer or locally recurrent cancer after BMT can be as high as 50%. 5,18,19 To our knowledge, the value of aggressive surveillance in terms of the success of implementation of salvage strategies has not been reported.…”

“…1 The purpose of surveillance is to provide salvage therapy to patients who develop LR only. SS for LR only after BMT is recommended if surgery is feasible.…”

“…6,7 We previously reported the rate of local relapses (LRs) in a smaller cohort of patients, 6,8 but the details of the timing and outcomes of salvage strategies in a larger group of patients have not been reported. Although the LR rate is low after TMT, 1,[9][10][11] it is higher without preoperative chemoradiotherapy 12 and it is considerably higher after BMT. 6,13 Another important question is whether surveillance of patients after BMT provides any benefit in those who develop an LR.…”

“…We have aggressively surveyed our patients who underwent TMT and BMT. We reported that aggressive surveillance in patients who have undergone TMT is most likely not warranted 1 ;…”

Esophageal cancer: comparative effectiveness of treatment options

“…36 Most studies published previously have also shown a reduction in LRR after preoperative CRT for esophageal cancer compared to surgery alone. 26,29,37,38 The LRR rates range from 5% to 14% and 34% to 42% after neoadjuvant CRT and surgery alone, respectively. 26,29,37,38 The recurrence outcomes in the CROSS study showed that preoperative CRT reduced the overall recurrence rate (surgery 58% vs preoperative CRT 35%) and that preoperative CRT reduced LRR from 34% to 14% (P,0.001) and peritoneal carcinomatosis from 14% to 4% (P,0.001).…”