Role of salvage esophagectomy after definitive chemoradiotherapy

Abstract

Chemoradiotherapy has become a popular definitive therapy among many patients and oncologists for potentially resectable esophageal carcinoma. Although the complete response rates are high and short-term survival is favorable after chemoradiotherapy, persistent or recurrent locoregional disease is quite frequent. Salvage surgery is the sole curative intent treatment option for this course. As experience with definitive chemoradiotherapy grows, the number of salvage surgeries may increase. Selected articles about salvage esophagectomy after definitive chemoradiotherapy for esophageal carcinoma are reviewed. The number of salvage surgeries was significantly lower than the number of expected candidates. To identify candidates for salvage surgery, patients undergoing definitive chemoradiotherapy should be followed up carefully. Salvage esophagectomy is difficult when dissecting fibrotic masses from irradiated tissues. Patients who underwent salvage esophagectomy had increased morbidity and mortality. Pulmonary complications such as pneumonia and acute respiratory distress syndrome were common. The anastomotic leak rate was significantly increased because of the effects of the radiation administered to the tissues used as conduits. The most significant factor associated with long-term survival appeared to be complete resection. However, precise evaluation of resectability before operation was difficult. Nevertheless, increased morbidity and mortality will be acceptable in exchange for potential long-term survival after salvage esophagectomy. Such treatment should be considered for carefully selected patients at specialized centers.

Re-irradiation of recurrent esophageal cancer after primary definitive radiotherapy

“…The local recurrence rate at the first site was reported to be approximately 44-61% [1,2]. All patients with locoregional recurrence died within 1 year without treatment [3]. If recurrence occurs, the 5-year survival rate drops to 0-11% [4-6].…”

“…Long-term survival after salvage esophagectomy was related to resection without residual tumors (R0). The 5-year survival rate after salvage esophagectomy was reported to be up to 25-35% [3,7]. For unresectable or medically inoperable esophageal cancer, best supportive care is recommended (including external beam radiation therapy, intraluminal brachytherapy, chemotherapy, hyperthermia, laser, dilatation, endoscopic mucosal resection, and stent insertion) [8,9].…”

Neoadjuvant Chemoradiotherapy Improving Survival Outcomes for Esophageal Carcinoma

“…Although patients with EC receiving NCRTS had higher SRs compared with patients with non-NCRTS, some studies indicated that patients who underwent NCRT after esophagectomy were inclined to higher incidences of morbidity and mortality. [10114043] Furthermore, complications and toxicity of NCRTS effectuated a negative impact on higher postoperative mortality and morbidity. [1144] These findings were ascribed to the nature of the selected patients and sample size; hence, a contradictive opinion in other studies has presented no increase in the incidence of postoperative mortality and morbidity, compared with the non-NCRTS group.…”

Local Control May be the Key in Improving Treatment Outcomes of Esophageal Squamous Cell Carcinoma Undergoing Concurrent Chemoradiation

“…For example, high-dose radiation therapy could substantially increase the risk of esophageal stricture and/or perforation, a potentially life-threatening complication. In contrast, some studies presented that some patients were cured with salvage esophagectomy after CCRT, and long-term survival was not worse than expected [18,19]. …”