Minimally Invasive Salvage Operations for Esophageal Cancer after Definitive Chemoradiotherapy

Abstract

Background/Aims: Because salvage surgery after definitive chemoradiotherapy for esophageal cancer is associated with high postoperative mortality and morbidity, minimally invasive methods are desirable. We analyzed the validity of minimally invasive salvage operations (MISO). Methods: Twenty-five patients underwent salvage operation between 2010 and 2016 in our institution, 10 having undergone right transthoracic salvage esophagectomy (TTSE group), 6 transhiatal salvage esophagectomy (THSE), 6 salvage lymphadenectomy (SLA), and 3 salvage endoscopic submucosal dissection (SESD). Patients who had undergone THSE, SLA, or SESD were categorized as the MISO group. Short- and long-term outcomes were assessed. Results: The mean duration of surgery was significantly shorter in the SLA groups than in the TTSE group (p = 0.0248). Blood loss was significantly less in the SLA than the TTSE group (p = 0.0340). Intensive care unit stay was shorter in the THSE than the TTSE group (p = 0.0412). There was no significant difference in postoperative mortality between the MISO and THSE groups. Postoperative hospital stay was significantly shorter in the SLA than the TTSE group (p = 0.0061). Patients’ survivals did not differ significantly between the MISO and TTSE groups (p = 0.752). Multivariate analysis revealed that residual disease (R0; HR 4.872, 95% CI 1.387–17.110, p = 0.013) was the only independent factor influencing overall survival. Conclusion: MISO is preferable because short-term outcomes are better and long-term outcomes do not differ from those of TTSE.

Salvage treatment after definitive chemoradiotherapy for esophageal squamous cell carcinoma

“…23,36 The rate of cT4 patients before dCRT varied from 8%-100% due to different patient selection criteria for each study. 19,20,22,[24][25][26]28,29,[33][34][35][36][37][38][39][40][41] Four articles analyzed cT4 cases only. 20,33,36,37 At present, dCRT is a standard therapeutic strategy for cT4 ESCC, but dCRT indications for cT4 patients might need to be revised because induction chemotherapy…”

“…47 R0 resection was performed in 42.4%-86.9% of cases. [18][19][20][21][22][23][24][25][26][27][28][29][33][34][35][36][37][38][39][40][41]44,46 One-year, 3-year, and 5-year OS rates were 45.7%-84%, 18,27,34,[36][37][38]40,46 29.8%-63%, 18,[26][27][28]34,38,40,46 and 5.7%-51.6%, 18,26,27,[34][35][36][37]46 respectively. Multivariate analysis revealed the following independent prognostic factors: R0 resection, 21,[23][24]…”

“…1,2 Salvage surgery is regarded as being difficult because of the indistinct planes between the tumor and fibrotic masses of the irradiated mediastinal tissues. 17 Previous studies showed the right transthoracic approach to have been mainly adopted for salvage esophagectomy, though minimally invasive esophagectomy (MIE) by thoracoscpic [18][19][20][21][22] and transhiatal approaches [23][24][25][26][27][28][29] have also been reported. Notably, Taniyama et al used the thoracoscopic approach for 95% of the salvage esophagectomy cases.…”

“…[18][19][20][21][22][23][24][25][26][27][28][29][33][34][35][36][37][38][39][40]44 Pulmonary complication rates ranged from 15.9%-44%. 18,19,[21][22][23][24][25][26][27][28][29][33][34][35][36][37][38][39][40] Recurrent nerve palsy rates ranged from 5.7% to 44.4%. 19,21,22,25,26,28,29,34,36,37 Chylothorax reportedly occurred in 0%-13.3% of the cases.…”

“…23,36 The rate of cT4 patients before dCRT varied from 8%-100% due to different patient selection criteria for each study. 19,20,22,[24][25][26]28,29,[33][34][35][36][37][38][39][40][41] Four articles analyzed cT4 cases only. 20,33,36,37 for cT4 patients has recently come to be regarded as an option, 42 and a phase III trial for cT4 ESCC and JCOG1510, comparing triple induction regimens with docetaxel, cisplatin, and 5-fluorouracil plus radical surgery to dCRT is ongoing.…”