Multimodal therapy for locally advanced esophageal carcinoma offers the highest probability of long-term overall and disease-free survival. However, the optimal multimodal treatment strategy is controversial. Morbidity rates after esophagectomy are high (30–60%) and mortality rates can exceed 20% in lower volume centers.1–3 Furthermore, with clinical trial data demonstrating pathologic complete response rates of 23–49% (depending on histology) after neoadjuvant chemoradiation4–6 and some studies demonstrating no survival advantage of esophagectomy as part of a multimodal treatment strategy over chemoradiation alone,7,8 many physiologically fit patients are treated with definitive chemoradiation therapy. However, even this strategy is far from optimal as chemoradiation therapy trials for locally advanced esophageal carcinoma have reported locoregional recurrence or progression rates of 25–60%.9–11 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 carefully selected patients in a final attempt to cure.
The term salvage esophagectomy lacks a consistent definition in the literature, making interpretation of the literature challenging. Some define a salvage resection based on the pretreatment plan. If the intent was to avoid surgery with definitive chemoradiation therapy, esophagectomy for persistent or recurrent disease in such patients is a “salvage” resection. Based on the results of RTOG 0246, a selective strategy to salvage resection involves evaluating only those patients who have an incomplete clinical response to chemoradiation therapy for esophagectomy.12 Others define salvage esophagectomy as a resection after a period of time, typically 3 months. Some of these patients had esophagectomy as part of the initial treatment plan; however, due to a decline in their performance status during chemoradiation, had the treatment plan changed to watchful waiting. Further adding to the heterogeneity of these patients are differences in the preoperative radiation dose and field. These subtle differences in the definition of salvage esophagectomy create two discrepant groups of patients—those who have avoided surgery by design and those who have avoided surgery out of necessity. Hence, the risk–benefit ratio is different between these groups of patient and must be taken into consideration when interpreting the literature and counseling patients for salvage esophagectomy.13 Finally, tumor histology has important implications given the differences in tumor biology and response rates of squamous cell carcinoma versus adenocarcinoma to chemoradiation therapy.4 Much of the literature on salvage esophagectomy is for squamous cell carcinoma.
Salvage Esophagectomy for Persistent or Locally Recurrent Disease After Definitive Chemoradiotherapy
In 2007, Gardner-Thorpe et al.14 reviewed nine single institution series of salvage esophagectomy following definitive chemoradiotherapy. A total of 105 patients, predominantly with squamous cell carcinoma, were included in the study. Salvage esophagectomy was an uncommon operation. Centers included in this study performed one to two salvage esophagectomies a year, representing 1.7% to 4.2% of their total esophagectomy volume. Morbidity was significant; three centers ...