Outcomes from salvage esophagectomy post definitive chemoradiotherapy compared with resection following preoperative neoadjuvant chemoradiotherapy

Abstract

Chemoradiotherapy (CRT) as a definitive treatment for esophageal cancer, is being used with increasing frequency and as a result, surgeons will be required to assess more patients who have residual or recurrent local malignancy. This article aimed to assess outcomes after esophagectomy following definitive CRT (dCRT) and compare any difference between them and patients who had preoperative neoadjuvant CRT (nCRT) using a similar regimen of chemotherapy. From a prospective database the details of patients who had a resection following nCRT and dCRT were analyzed. The main therapeutic difference between the groups was the dose of radiotherapy (35 vs 60 Gy) and the timing of the resection following completion of the CRT (median 4 vs 28 weeks). Fourteen patients had an esophagectomy following a dCRT and 53 had one following a nCRT. Preoperatively, the dCRT group had worse respiratory function and more ECG abnormalities. Preoperative tumor length, pathological TNM staging and R0 resection rates were the same in both groups. Post resection, the dCRT group had greater morbidity than the nCRT group, spending longer in the intensive care unit (median 48 vs 24 h), more days in hospital (median 31 vs 13) and having more severe respiratory complications (37%vs 6%). The operative mortality was higher in the dCRT group (7%vs 0%). The three-year survival was 24% after dCRT. Patients selected for salvage esophagectomy following dCRT are a major challenge in postoperative care. However, some patients survive for a reasonable period of time, making resection a worthwhile option.

Salvage esophagectomy: safe therapeutic strategy?

“…The pooled analysis of five studies (14)(15)(16)18,20), revealed a significant increased incidence of overall postoperative morbidity in the salvage group (POR =1.30; 95% CI, 1.00-1.67, P=0.046). There was no evidence of significant statistical heterogeneity (I HR, hazard ratio.…”

“…After screening, one further publication (23), was excluded as this institution published their outcomes in a follow-up publication, which was included in the analysis (16). Therefore, ten comparative studies were included in this pooled final analysis (13)(14)(15)(16)(17)(18)(19)(20)(21)(22). In total 1,906 patients were included, 563 in the salvage group and 1,343 in the NCRS group.…”

“…Eleven studies were identified in the initial literature search to meet inclusion criteria ( Figure 1) (13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23). After screening, one further publication (23), was excluded as this institution published their outcomes in a follow-up publication, which was included in the analysis (16).…”

Multimodal Therapies for Upper Gastrointestinal Cancers – Past, Now, and Future

“…However, salvage surgery is a highly invasive and complex treatment leading to increased morbidity (50-79%) and in-hospital mortality (7-22%) as compared with those after neoadjuvant CRTx, due to the adverse events of predominantly respiratory complications and anastomotic leakage (Chao et al, 2009;Nakamura et al, 2004;M. Nishimura et al, 2007;Oki et al, 2007;Smithers et al, 2007;Swisher et al, 2002;Tachimori et al, 2009;Tomimaru et al, 2006). These hospital mortality rates are obviously higher than those for esophagectomy in Japan reported from specialized centers (2%) (Tachimori et al, 2009) or the nationwide registry (5%) (The Japan Esophageal Society).…”

Multimodal Treatment for Cancer of the Esophagus

“…The incidence of postoperative mortality was assessed in a considerable number of studies [61][62][63][64][65], fewer assessed in-hospital mortality, and 30-day mortality was determined in two studies [66]. Values were higher in patients who were treated with salvage esophagectomy after deinitive chemoradiotherapy (23 patients-9.50%) than in patients who treated with planned esophagectomy after neoadjuvant chemoradiotherapy (29 patients-4.07%).…”