26: Salvage Surgery for Recurrent Esophageal Cancer

Introduction

Recurrent (after a disease-free period) or persistent esophageal cancer following definitive therapy, particularly for locally advanced cancer, is common. Treatment failure following definitive chemoradiotherapy in RTOG-8501 was 46% at a minimum of 5 years follow-up.¹ Twenty percent of patients had recurrence after clinical complete response and 26% persistent cancer. In RTOG-8911 following R0 esophagectomy, at a median follow-up of 8.8 years, cancer recurrence was reported in 52% of patients receiving induction chemotherapy and 56% of patients with esophagectomy alone.²

Treatment of recurrent or persistent esophageal cancer after primary therapy is typically palliative and most commonly nonsurgical. However, in rare situations, salvage esophagectomy has been reported to be useful in highly selected patients in a final attempt to cure. To determine indications for salvage esophagectomy, the literature must be carefully assessed.

Literature Review

Failed Definitive Chemoradiotherapy

In 2007, Gardner-Thorpe et al.³ reviewed nine single institution series of salvage esophagectomy following definitive chemoradiotherapy. A total of 105 patients, predominantly with squamous cell carcinoma, were included in this simple evaluation. Salvage esophagectomy was an uncommon operation. With centers performing one to two salvage esophagectomies a year, this represented 1.7% to 4.2% of their esophagectomy volume. Morbidity was significant and three centers reported it was more than following neoadjuvant chemoradiotherapy. Anastomotic leak was reported in 18% of patients and conduit complications (necrosis and fistula) in 5%. Complications accounted for 42% of the 11% in-hospital mortality. Median survival ranged from 7 to 32 months. Almost all deaths after discharge were due to cancer. R0 resection was associated with improved survival in four series. In three series, no patient with R1 or R2 resection survived more than 13 months. There was some evidence that patients with recurrent cancer after chemoradiotherapy did better than those with persistent cancer.

Nishimura et al.⁴ reported results of salvage esophagectomy in 46 patients treated 1 to 7 months following definitive chemoradiotherapy. This group comprised 16% of patients with persistent or recurrent cancer after chemoradiotherapy. Operative mortality was 15%. Complications were frequent; the most common was anastomotic leak in 22% of patients. Median survival was 22 months, and 3-year survival was 17%. There were no clear predictors of survival; however, the three long-term survivors were ypN0 at salvage esophagectomy.

Piessen et al.⁵ reported salvage esophagectomy in 98 (20%) of 472 patients treated with definitive chemoradiotherapy. Sixty-two percent had R0 resection which was associated with improved median survival, 19 months in R0 patients versus 9 months in R1 and R2 patients (p < 0.001). In-hospital mortality was 3.1% and morbidity 33%. There were no R1 or R2 survivors after 26 months. Predictors of R0 resection were cancer length ≤5 cm on barium esophagram (p = 0.05) and contact between the primary cancer and aorta ≤90° on CT (p = 0.04).

D'Journo ...