Salvage esophagectomy after definitive chemotherapy and radiotherapy for advanced esophageal cancer

Optimizing Organ-Preservation Strategies Through Chemotherapy-Based Selection in Esophageal Squamous Cell Carcinoma: Results From the CROC Multi-Institutional Phase 2 Clinical Trial

PURPOSE

This study aimed to assess the viability of definitive chemoradiotherapy (dCRT) as an organ-preservation strategy for remarkable responders who were downstaged to stage IA after receiving induction chemotherapy for resectable esophageal squamous cell carcinoma (ESCC).

METHODS AND MATERIALS

Chemotherapy-naïve patients with resectable ESCC (stage IB-III, Union for International Cancer Control, International Cancer Control seventh edition) were eligible for the study. All patients received 3 cycles of docetaxel, cisplatin, and 5-FU (DCF) therapy (docetaxel 75 mg/m2 on day 1, cisplatin 75 mg/m2 on day 1, and 5-fluorouracil [5-FU] 750 mg/m2 on days 1-5, repeated every 3 weeks). Remarkable response was defined as a reduction in the tumor to T1, metastatic lymph nodes <1 cm on the short axis, and downstaging to stage IA after 3 cycles of DCF therapy. Remarkable responders then underwent dCRT, which included 2 courses of cisplatin 75 mg/m2 and 5-FU 1000 mg/m2 on days 1 to 4, repeated every 4 weeks, along with 50.4 Gy of concurrent radiation therapy. The primary endpoint was 1-year progression-free survival in remarkable responders following DCF therapy and subsequent dCRT. Secondary endpoints included 3-year overall survival (OS) and esophagectomy-free survival.

RESULTS

Of the 92 patients registered, 90 were analyzed. A remarkable response to 3 courses of DCF therapy was observed in 58.4% of patients. Among these responders, 89.8% achieved a complete response after dCRT. During the median follow-up period of 33 months (range, 1-85 months), the 1-year progression-free survival was 89.8% (95% confidence interval [CI], 77.2%-95.6%, primary endpoint), and the 3-year OS was 83.7%. The 3-year OS and esophagectomy-free survival rates in the analysis group were 74.1% and 45.3%, respectively. An 18F-fluorodeoxyglucose-positron emission tomography response after 2 courses of DCF therapy was significantly associated with OS (P = .0049).

CONCLUSIONS

In patients with resectable ESCC, dCRT for remarkable responders downstaging to stage IA after induction chemotherapy with 3 courses of DCF therapy is a feasible treatment option and provides an optimizing organ-preservation strategy of chemotherapy-based selection.

The feasibility of post-photodynamic therapy salvage esophagectomy in patients with esophageal squamous cell carcinoma treated with definitive chemoradiotherapy

BACKGROUND

Photodynamic therapy (PDT) is a minimally invasive salvage treatment for local residual or recurrent lesions that persist after the definitive chemoradiotherapy (dCRT) of esophageal cancer. However, esophageal cancer persistence after PDT is associated with a poor prognosis. Although esophagectomy is a curative treatment option, few studies have evaluated its efficacy. Thus, this study aimed to evaluate the outcomes of salvage esophagectomy after PDT.

METHODS

14 patients who underwent salvage esophagectomy for residual or recurrent esophageal cancer after PDT between April 2006 and November 2022 at our institution, were enrolled. The short-term (e.g., blood loss, operative time, R0 rate, postoperative complications, and postoperative hospital stay) and long-term (e.g., overall survival [OS] and recurrence-free survival [RFS]) of salvage esophagectomy after PDT were evaluated retrospectively.

RESULTS

The median operative time and intraoperative blood loss were 355 min and 350 ml, respectively. Eight patients (57.1%) had postoperative complications of Clavien-Dindo grade II or more. The median postoperative hospital stay was 20.5 days. The 3-year OS and RFS rates were 23.5% (95% confidence interval [CI] 5.7-48.0) and 16.3% (95% CI 2.7-40.3), respectively. Seven patients with an R0 had significantly longer OS than the seven patients with R1 and 2 (p = 0.045). The 3-year OS rate for patients with R0 was 52.6%.

CONCLUSIONS

Although salvage esophagectomy after PDT carries certain risks, patients who achieved an R0 had a promising long-term prognosis. The location and size of the lesion may be critical factors in determining whether R0 can be achieved with salvage esophagectomy after PDT.

Planned oesophagectomy after chemoradiotherapy versus salvage oesophagectomy following definitive chemoradiotherapy: a systematic review and meta-analysis

BACKGROUND

Oesophageal cancer is the eighth most common cancer and sixth leading cause of cancer-related mortality worldwide. Salvage oesophagectomies are associated with an increased risk of mortality, although recent data suggests that long-term survival rates following salvage oesophagectomy are similar to planned oesophagectomy. The aim was therefore to meta-analyse outcomes for patients undergoing salvage versus planned oesophagectomies to assess the differences in short-term mortality and long-term survival.

METHODS

A systematic review of Medline, Scopus, Web of Science and PubMed was performed to identify relevant studies. Data were extracted and compared by meta-analysis, using odds ratio and mean differences with 95% confidence intervals.

RESULTS

Nineteen studies meeting inclusion criteria were included in the meta-analysis, which compared patients in the planned oesophagectomy group (n = 23 555) to patients in the salvage oesophagectomy group (n = 2227). There were significant differences between the groups in terms of rates of postoperative mortality (5.7% salvage oesophagectomy versus 3.1% planned oesophagectomy, P = 0.0004), anastomotic leak (20.6% salvage oesophagectomy versus 14.5% planned oesophagectomy, P < 0.00001), pulmonary complications (37.1% salvage oesophagectomy versus 24.2% planned oesophagectomy, P < 0.0001) and R0 margin (87.6% salvage oesophagectomy versus 91.3% planned oesophagectomy, P < 0.0001). There was no statistical difference between long-term survival rates at 5 years with 39.2% for salvage and 42.6% for planned oesophagectomy (P = 0.28).

CONCLUSIONS

Salvage oesophagectomies do offer a meaningful chance of long-term survival (at 5 years) for select patients with oesophageal cancer, but the elevated risk of post-operative complications and mortality following salvage oesophagectomy should be recognized.

Multimodal Treatment Strategies to Improve the Prognosis of Locally Advanced Thoracic Esophageal Squamous Cell Carcinoma: A Narrative Review

Esophageal cancer is the seventh most common malignancy and sixth most common cause of cancer-related death globally. Esophageal squamous cell carcinoma (ESCC) with aortic or tracheal invasion is considered unresectable, and has an extremely poor prognosis; its standard treatment is definitive chemoradiotherapy (dCRT). In recent years, induction chemotherapy (ICT) has been reported to yield high response rates for locally advanced ESCC, and the efficacy and safety of ICT followed by conversion surgery (CS) have been investigated. Multimodal treatment, combining surgery with induction chemoradiotherapy (ICRT) or ICT, is necessary to improve ESCC prognosis. CS is generally performed for locally advanced ECC after ICRT or ICT when tumor downstaging is achieved, although its prognostic benefit remains controversial. The Japan Clinical Oncology Group (JCOG) has conducted a three-arm phase III randomized controlled trial (JCOG1510) to confirm the superiority of DCF (docetaxel, cisplatin, and 5-fluorouracil) ICT, over conventional dCRT, among patients with initially unresectable ESCC. In recent years, researchers have reported favorable outcomes of induction therapy followed by CS and salvage surgery, after dCRT or systemic immunochemotherapy. In this review, we will describe the latest developments in the multimodal treatment including chemotherapy, CRT, surgery, and immunotherapy, which may improve oncological and survival outcomes for patients with cT4 ESCC.

Combination of photodynamic therapy and endoscopic mucosal resection for recurrent esophageal squamous cell carcinoma after chemoradiotherapy

Photodynamic therapy (PDT) was developed for residual or recurrent esophageal cancer after radiotherapy. Here, we report a case of successful treatment of highly elevated esophageal squamous cell carcinoma (ESCC) that recurred after definitive chemoradiotherapy (dCRT) using PDT combined with endoscopic resection (ER). An 86-year-old man was found to have an ESCC in the mid-thoracic esophagus. One year and two months after dCRT, a local recurrence was seen. The recurrent ESCC had a highly elevated component. The ESCC was estimated to have invaded the deep submucosa at the highly elevated component. PDT was selected as a treatment option since no lymph node or distant metastases were found. However, there was concern that the laser would not be able to penetrate deep into the ESCC due to its high elevated component. Therefore, ER was performed to remove the highly elevated component, and PDT was performed later. However, after the ER, the circumference of the recurrent ESCC was found to be approximately half the circumference, and post-PDT stenosis was also a concern due to the wide circumference of the ESCC. Therefore, we limited the area of laser irradiation in one session of PDT. Four sessions of PDT were needed over 13 months, but a local complete response was achieved without adverse events.

Recurrent metastasis risk factors in esophageal cancer after salvage endoscopic resection for local failure following chemoradiotherapy

OBJECTIVES

Although salvage endoscopic resection is an optimal treatment for local failure after chemoradiotherapy for esophageal squamous cell carcinoma, recurrent metastasis (lymph node and/or distant metastasis) after salvage endoscopic resection may occur with a certain degree of unavoidable frequency and is associated with a poor prognosis. However, the risk factors for recurrent metastasis are unclear. This study aimed to evaluate the risk factors for recurrent metastasis after salvage endoscopic resection.

METHODS

Patients who underwent salvage endoscopic resection for local failure after chemoradiotherapy/radiotherapy were analyzed in this single-center, retrospective study. We evaluated the cumulative incidence rates of recurrent metastases, overall survival, and the risk factors for recurrent metastasis after salvage endoscopic resection.

RESULTS

We analyzed 132 patients. The 5-year cumulative incidence rate of recurrent metastases after salvage endoscopic resection was 25.7%. The 5-year overall survival rates in all patients and in patients with recurrent metastasis were 66.8% and 22.5%, respectively. Local failure pattern with a residual lesion after chemoradiotherapy/radiotherapy (subdistribution hazard ratio 2.34; P = 0.012) and the presence of lymphatic invasion in salvage endoscopic resection specimen (subdistribution hazard ratio 3.20; P = 0.002) were significant risk factors for recurrent metastasis.

CONCLUSIONS

Patients with local failure pattern with a residual lesion after chemoradiotherapy/radiotherapy and presence of lymphatic invasion have a high risk for recurrent metastasis. Thus, appropriate surveillance for these patients should be considered.

Association between Submucosal Fibrosis and Endoscopic Submucosal Dissection of Recurrent Esophageal Squamous Cell Cancers after Chemoradiotherapy

Simple Summary

The efficacy and safety of endoscopic submucosal dissection for early esophageal cancer after chemoradiotherapy have not been established. In this study, we focused on the fibrosis of the submucosa. As a result, we found that endoscopic submucosal dissection for early esophageal cancer can be performed reliably without adverse events, but the procedure takes longer for lesions with strong fibrosis of the submucosa.

Abstract

Endoscopic resection is a treatment of choice for a metachronous early-stage esophageal squamous cell carcinoma (ESCC) appearing after a radical cure of esophageal cancer by chemoradiotherapy (CRT). However, non-curative resection, and procedural complications including perforation due to radiation-induced submucosal fibrosis, are a concern. This study aimed to evaluate the association between submucosal fibrosis and the usefulness and safety of endoscopic submucosal dissection (ESD) in ESCC after CRT. This study retrospectively analyzed 13 lesions in 11 patients in our institute. Submucosal fibrosis under the lesion (F score) was classified into three levels (F0: none or mild, F1: moderate, and F2: severe) based on endoscopic and histopathologic findings. All lesions were F1 or greater (F1: 8 lesions and F2: 5 lesions). En bloc and R0 resection rates were both 100%. The procedural speed was slower in F2 than in F1 (F1 vs. F2; 15.1 mm²/min vs. 7.1 mm²/min, p = 0.019), without procedure-related adverse events. At a median follow-up of 42 months (range: 14–117 months) after ESD, 7 of 11 (63.6%) patients were alive without recurrence, and without ESCC-related death. ESCC after CRT reliably and safely resected en bloc by ESD but was more difficult in lesions with strong submucosal fibrosis.

Salvage endoscopic resection for cT1N0M0 local recurrence after chemoradiotherapy for esophageal squamous cell carcinoma: endoscopic submucosal dissection versus endoscopic mucosal resection

OBJECTIVES

Salvage endoscopic resection is recommended when the local recurrence at primary site after chemoradiotherapy for esophageal squamous cell carcinoma is localized and superficial. This retrospective study aimed to comparatively analyse the short-term outcomes and local control of salvage endoscopic submucosal dissection versus salvage endoscopic mucosal resection for local recurrence after chemoradiotherapy or radiotherapy.

METHODS

A total of 96 patients who underwent initial salvage endoscopic resection for cT1N0M0 local recurrence after chemoradiotherapy or radiotherapy for esophageal squamous cell carcinoma between December 1998 and August 2019 patients were assigned to either the salvage endoscopic submucosal dissection (40 patients; 40 lesions) or salvage endoscopic mucosal resection (56 patients; 56 lesions) group. We evaluated the en bloc and R0 resection rates, severe adverse events and local failure rate after salvage endoscopic resection. Multivariate analysis was conducted to identify risk factors of local failure after salvage endoscopic resection.

RESULTS

The en bloc resection rate was significantly higher in the salvage endoscopic submucosal dissection group than in the salvage endoscopic mucosal resection group (95% versus 63%; P < 0.001). There were no differences in R0 resection rate between the two groups (73% versus 52%, P = 0.057). One patient (3%) in the salvage endoscopic submucosal dissection group had perforation. The 3-year cumulative local failure rate of salvage endoscopic mucosal resection was significantly higher than that of salvage endoscopic submucosal dissection (27% versus 5%, P = 0.032). In multivariate analysis, salvage endoscopic mucosal resection (hazard ratio: 2.7, P = 0.044) was the only independent risk factor of local failure after salvage endoscopic resection.

CONCLUSIONS

Salvage endoscopic submucosal dissection is the effective treatment for local recurrence based on the short-term outcomes and local efficacy.

Salvage Surgery for Recurrent Disease after Definitive Chemoradiotherapy for Esophageal Squamous Cell Carcinoma

BACKGROUND

Outcomes of salvage surgery after failed definitive chemoradiation (CRT) for esophageal cancer have been well defined. However, only a few studies have focused on salvage esophagectomy for recurrent disease after CRT.

METHODS

In 227 patients with esophageal cancer who underwent salvage esophagectomy after definitive CRT, consisting of 116 patients who underwent esophagectomy for persistent disease (the persistent group) and 111 patients who underwent esophagectomy for recurrent disease (the recurrent group), the short- and long-term outcomes were investigated.

RESULTS

The rates of any postoperative complication were similar between the groups (49.1% in the persistent group vs. 49.5% in the recurrent group, p = 0.951), although there was a higher rate of anastomotic leakage in the recurrent group (p = 0.027). Thirty-day mortality was also similar between the groups (1.7% in the persistent group vs. 0.9% in the recurrent group, p = 0.587). The 3-year and 5-year overall survival rates were 33.7% and 28.0% in the persistent group and 48.7% and 41.7% in the recurrent group, respectively (p = 0.0175). In the recurrent group, clinically nodal status before CRT as well as pathologically nodal status and time to relapse were identified as independent prognostic factors. In the persistent group, pT and resection margin were identified as independent factors associated with survival.

CONCLUSIONS

The present study showed that salvage surgery for recurrent disease can provide acceptable short- and long-term outcomes. Considering clinically and pathologically nodal status and time to relapse, adjuvant therapy might be offered for patients who underwent salvage esophagectomy for recurrent disease after definitive CRT.

Omitting surgery in esophageal cancer patients with complete response after neoadjuvant chemoradiotherapy: a systematic review and meta-analysis

BACKGROUND

Neoadjuvant chemoradiotherapy (nCRT) followed by surgery is a standard treatment modality for locally-advanced esophageal cancer. However, patients who achieve clinical complete response (cCR) after nCRT have been reported to have better prognosis. Further, the role of surgery in these patients is controversial. Thus, this meta-analysis aimed to evaluate whether surgery is still useful in patients with cCR after nCRT.

METHODS

We systematically reviewed the MEDLINE, PubMed, Embase, Cochrane library, and Scopus databases for studies on surgical efficacy in complete responders after concurrent chemoradiotherapy for esophageal cancer. The publication date was set to January 1, 2010-January 31, 2020. The hazard ratio (HR) and risk ratio were used to compare the 2-year overall survival (OS), disease-free survival (DFS), incidence of locoregional failure, distant metastasis, and treatment mortality between the nCRT and nCRT plus surgery groups.

RESULTS

Six articles involving 609 patients were included. There was a significant benefit of nCRT for OS (HR = 0.80, 95% confidence interval [CI] 0.64-0.99, p = 0.04), but not for DFS (HR = 1.55, 95% CI 0.35-6.86, p = 0.56). The nCRT group tended to have lower mortality than the nCRT plus surgery group (risk ratio = 0.15, 95% CI 0.02-1.18, p = 0.07).

CONCLUSION

Omitting surgery provides better OS in complete responders after nCRT. Adding surgery could increase the morbidity and mortality and decrease the quality of life. Thus, nCRT alone could be a feasible approach for patients with cCR.

Salvage Esophagectomy

Salvage esophagectomy is an option for patients with recurrent or persistent esophageal cancer after definitive chemoradiation therapy or those who undergo active surveillance after induction chemoradiation therapy. Salvage resection is associated with higher rates of morbidity compared with planned esophagectomy but offers patients with locally advanced disease a chance at improved long-term survival. Salvage resection should be preferentially performed in a multidisciplinary setting by high-volume and experienced surgeons. Technical considerations, such as prior radiation dosage, radiation field, and choice of conduit, should be taken into account.

Analysis of trimodal and bimodal therapy in a selective-surgery paradigm for locally advanced oesophageal squamous cell carcinoma

BACKGROUND

Long-term survival outcomes of trimodal therapy (TMT; chemoradiation plus surgery) and bimodal therapy (BMT; chemoradiation) have seldom been analysed. In a selective-surgery paradigm, the benefit of TMT in patients with a complete clinical response is controversial. Factors associated with survival in patients with a clinical complete response to chemoradiation were evaluated.

METHODS

Patients with stage II-III oesophageal squamous cell carcinoma treated with TMT or BMT from 2002 to 2017 were evaluated. The BMT group consisted of patients who were otherwise eligible for surgery but underwent chemoradiation alone followed by observation. This group included patients who later had salvage oesophagectomy. Survival was evaluated and compared between TMT and BMT groups. Elastic net regularization was performed to select co-variables for Cox multivariable survival analysis in patients with a clinical complete response.

RESULTS

Of 143 patients, 60 (41.9 per cent) underwent TMT and 83 (58.0 per cent) BMT. Patients who underwent TMT had longer median overall survival than those who had BMT (77 versus 33 months; P = 0.019). For patients with a clinical complete response, TMT achieved longer median overall survival than BMT (123 versus 55 months; P = 0.04). BMT had a high locoregional recurrence rate (48 versus 6 per cent; P < 0.001); 26 of 29 patients with locoregional recurrence in the BMT groupunderwent salvage resection. Cox multivariable analysis demonstrated that upper-mid oesophageal tumour location (hazard ratio (HR) 2.04; P = 0.024) and tumour length (HR 1.18; P = 0.046) were associated with worse survival. Although TMT was not associated with survival, it was a predictor of reduced recurrence (HR 0.28; P = 0.028). The maximum standardized uptake value after chemoradiation also predicted recurrence (HR 1.33; P < 0.001).

CONCLUSION

In patients who achieve a clinical complete response, TMT reduces locoregional recurrence but may not prolong survival. The differences in survival outcomes may be due to patient selection; therefore, a selective-surgery strategy in oesophageal squamous cell carcinoma is a reasonable approach.

Advantageous factors of R0 curative conversion esophagectomy and the optimal extent of lymphadenectomy after induction therapy for cT4b thoracic esophageal cancer

AIM

This study aimed to clarify the prognostic factors, the advantageous factors of R0 curative resection, and optimal extents of lymph node dissection for conversion esophagectomy after induction therapy.

METHODS

Among 1903 patients with esophageal cancer at Toranomon Hospital between January 2006 to May 2020, 151 patients with locally advanced T4b thoracic esophageal cancer were divided into two groups according to treatment: conversion surgery group (n = 54) and non-surgical treatment group (n = 97) for comparison.

RESULTS

The patients who underwent R0 curative resection showed preferable survival comparable to the survival rate of patients with cCR in the non-surgical treatment group (1-, 3- and 5-year survival: 96.9%, 82.1% and 76.7% vs 94.1%, 86.3%, and 86.3%; P = 0.770). Multivariate analysis revealed that the T4b tumor invasion by primary site (odds ratio (OR) = 6.100; 95% CI, 1.439-25.865: P = 0.014) and time to conversion surgery from start of induction therapy within four months (OR = 5.229; 95% CI, 1.296-21.102: P = 0.020) were all independent advantageous factors of R0 curative resection. Actuarial 1-, 3- and 5-year survival rates in patients who underwent conversion surgery with D2-3 lymphadenectomy were 90.9%, 48.6%, and 40.8%, respectively.

CONCLUSIONS

R0 resection led to improved prognosis in conversion esophagectomy for cT4b esophageal cancer. The T4b tumor invasion by primary site and time to conversion surgery from start of induction therapy within 4 months were independent advantageous factors of R0 curative resection. In addition, standard radical esophagectomy including prophylactic D2-/3- lymphadenectomy should be performed if it is possible, while taking adequate care regarding the increased risk after induction therapy.

Association of local complete response with prognosis after salvage photodynamic therapy for esophageal squamous cell carcinoma

OBJECTIVES

Photodynamic therapy (PDT) is an effective salvage endoscopic treatment for local failure at the primary site after chemoradiotherapy (CRT) in esophageal cancer patients. However, the contribution of local control by salvage PDT to the prognosis is unclear. We investigated whether complete response at primary site by salvage PDT could improve the prognosis.

METHODS

Between January 2008 and March 2016, 34 patients received salvage PDT for local failure of esophageal cancer limited to stage T1-2 after definitive CRT or radiotherapy. Local complete response (L-CR) rate, adverse events, overall survival (OS), and progression-free survival (PFS) were assessed retrospectively.

RESULTS

Local complete response rates after PDT were 68% (23/34; 95% CI, 50-83%) in all patients: 81% (17/21; 95% CI, 58-95%) for stage T1 and 46% (6/13; 95% CI, 19-75%) for stage T2 patients. Grade 3 esophageal stricture occurred in one patient. The median follow-up was 26.0 months (range, 3.7-93.6 months); 21 patients died. The median survival times were 54.3 months in patients who achieved L-CR after PDT (L-CR group) and 19.8 months in those who did not (non-CR group). The 2-year OS rates were 79% (95% CI, 54-92%) in the L-CR group and 40% (95% CI, 11-68%) in the non-CR group (P = 0.0389; log-rank test). The median PFS was 21.2 months in the L-CR group and 1.9 months in the non-CR group (P < 0.001; log-rank test).

CONCLUSION

Achieving L-CR by salvage PDT for local failure after CRT in esophageal cancer was associated with good prognosis.

Repeated talaporfin sodium photodynamic therapy for esophageal cancer: safety and efficacy

BACKGROUND

Talaporfin sodium photodynamic therapy (tPDT) is an effective salvage treatment for local failure after chemoradiotherapy for esophageal cancer. Repeated tPDT could also be indicated for local recurrence or residue after the first salvage tPDT. However, the safety and efficacy of repeated tPDT have not been elucidated.

METHODS

We reviewed 52 patients with esophageal cancer who were treated with the first tPDT at Kyoto University Hospital between October 2015 and April 2020.

RESULTS

Among 52 patients, repeated tPDT after the first tPDT was indicated for 13 patients (25%), of which six had residual tumor, four had local recurrence after complete response (CR) after the first tPDT at the primary site, and six had metachronous lesion. The total session of repeated tPDT was 25; 16 were for primary sites and nine were for metachronous sites. Among them, six patients (46.2%) achieved local (L)-CR and nine lesions (56.3%) achieved lesion L-CR. By session, 10 sessions (40%) achieved L-CR. There were no severe adverse events except for one patient; this patient showed grade 3 esophageal stenosis and perforation after the third tPDT on the same lesion that was previously treated with porfimer sodium photodynamic therapy four times.

CONCLUSION

Repeated tPDT could be an effective and safe treatment for local failure even after salvage tPDT for esophageal cancer.

It's not always too late: a case for minimally invasive salvage esophagectomy

INTRODUCTION

Standard of care for locally advanced esophageal carcinoma is neoadjuvant chemoradiation (nCRT) and surgical resection 4-8 weeks after completion of nCRT. It is recommended that the CRT to surgery interval not exceed 90 days. Many patients do not undergo surgery within this timeframe due to patient/physician preference, complete clinical response, or poor performance status. Select patients are offered salvage esophagectomy (SE), defined in two ways: resection for recurrent/persistent disease after complete response to definitive CRT (dCRT) or esophagectomy performed > 90 days after completion of nCRT. Salvage esophagectomy reportedly has higher postoperative morbidity and poor survival outcomes. In this study, we assessed outcomes, overall, and disease-free survival of patients undergoing salvage esophagectomy by both definitions (recurrent/persistent disease after dCRT and/or > 90 days), compared to planned (resection after nCRT/within 90 days) esophagectomy (PE).

MATERIALS AND METHODS

Retrospective review of a prospectively maintained database identified patients who underwent minimally invasive esophagectomy at a single institution from 2009 to 2019. Esophagectomy for benign disease and patients who did not receive nCRT were excluded. Outcomes included postoperative complications, length of stay (LOS), disease-free survival, and overall survival.

RESULTS

97 patients underwent minimally invasive esophageal resection for esophageal carcinoma. 89.7% of patients were male. Mean age was 64.9 years (range 36-85 years). 94.8% of patients had adenocarcinoma, with 16 transthoracic and 81 transhiatal approaches. On comparing planned esophagectomy (n = 87) to esophagectomy after dCRT failure (n = 10), no significant differences were identified in overall survival (p = 0.73), disease-free survival (p = 0.32), 30-day or major complication rate, anastomotic leak, or LOS. Similarly, when comparing esophagectomy < 90 days after CRT (n = 62) to > 90 days after CRT completion (n = 35), no significant differences were identified in overall survival (p = 0.39), disease-free survival (p = 0.71), 30-day or major complication rate, LOS, or anastomotic leak rate between groups. In this comparison, local recurrence was noted to be elevated with SE as compared to PE (64.3% vs. 25.0%, p = 0.04).

CONCLUSION

Overall survival and disease-free survival were equivalent between SE and PE. Local recurrence was noted to be increased with SE, though this did not appear to affect survival. Although planned esophagectomy remains the standard of care, salvage esophagectomy has comparable outcomes and is appropriate for selected patients.

Patient selection for salvage surgery after definitive chemoradiotherapy in esophageal squamous cell carcinoma

PURPOSE

With the widespread use of definitive chemoradiotherapy (dCRT) for esophageal squamous cell carcinoma (ESCC), salvage surgery for recurrence/residual patients became prevalent. However, survival impact of salvage surgery remains obscure at present.

METHODS

The updated clinical outcomes of salvage surgery were investigated to know its survival impact. Of the 155 ESCC patients who underwent dCRT between 2009 and 2016, we included 85 patients with recurrence or residual disease. The median follow-up was 65 months.

RESULTS

Of the 85 patients with progression disease, there were 42 and 43 patients of recurrence and residual disease, respectively. Salvage surgery was performed in 27 patients after dCRT, including 15 patients who underwent salvage esophagectomy. The 5-year overall survival (OS) of salvage surgery and otherwise patients was 66.1% and 14.5%, and the patients with salvage surgery had a significantly better prognosis (p < 0.0001). In the 15 patients who underwent salvage esophagectomy, residual disease, lymph node metastasis-positive (ycN+) after dCRT, and pathological lymph node metastasis-positive (ypN+) were significantly associated with poor prognosis (p = 0.0492, p = 0.0006, p = 0.0276), and the 5-year OS rates for the ycN/ypN combinations were 90%, 33.3%, and 0% in ycN-/ypN-, ycN+/ypN-, and ycN+/ypN+ patients, respectively (p = 0.0026). In a multivariate analysis, ycN+ was an independent poor prognostic factor (HR 13.6, 95% CI 1.65-286.8, p = 0.0154).

CONCLUSIONS

Survival impact of salvage surgery after dCRT is robust, and lymph node metastasis after dCRT may help determine the indication for salvage esophagectomy.

Esophageal brachytherapy: Institut Gustave Roussy's experience

PURPOSE

Esophageal cancer is characterized by its propension to local evolution, which conditions prognosis and quality of life. Brachytherapy may be a therapeutic option for all stages of esophageal cancer.

METHODS AND MATERIALS

This retrospective unicentric study included all consecutive patients treated for an esophageal high-dose-rate brachytherapy in our institution from 1992 to 2018.

RESULTS

Ninety patients were included. They were treated in four distinct indications: exclusive (7 patients), boost after external beam radiotherapy (41), reirradiation (36), or palliative aim (6). Most frequently prescribed schemes were 3 × 5 Gy (boost) or 6 × 5 Gy (exclusive treatment and reirradiation) at applicator's surface or at 5 mm. At the end of follow-up, 50% of patients had presented with local recurrence. Seventeen percent of patients had a metastatic relapse. Median overall survival was 15 months in the whole cohort: 22 months in the boost setting, 25 months for exclusive brachytherapy, 15 months for reirradiation, and only 2 months for palliative treatment. Tumor length at brachytherapy, brachytherapy dose, and interfraction response were significantly associated to overall survival. 40% of patients presented with grade 2+ toxicity, mostly esophagitis, including three toxic deaths.

CONCLUSIONS

Although local control outcomes are still poor, one must remember that patients are unfit for any curative therapeutic option and that palliative chemotherapy offers mediocre results. The most promising setting probably is reirradiation because brachytherapy offers a remarkable dose gradient allowing best organ at risk sparing, with an encouraging rate of long survivors (19% at 2 years). Esophageal brachytherapy deserves to be further investigated because some patients, even unfit, may benefit from it, with acceptable toxicity.

Efficacy of traction, using a clip-with-thread, for esophageal endoscopic submucosal dissection for esophageal lesions with fibrosis in an ex vivo pig training model

BACKGROUND/AIMS

Endoscopic submucosal dissection (ESD) of recurrent esophageal carcinoma is technically difficult to perform due to submucosal fibrosis that develops after definitive chemoradiation therapy. Therefore, our aim was to evaluate the usefulness of clip-with-thread traction for ESD of esophageal lesions with submucosal fibrosis.

MATERIALS AND METHODS

Four endoscopists excised 16 lesions by ESD in an ex vivo pig training model. Mock lesions (30 mm in diameter) were created, including a 10-mm area of submucosal fibrosis in the center of each lesion. Each endoscopist performed two ESDs with traction (ESD-T) and two without traction (ESD-N). The primary outcome was the time required for submucosal dissection. Secondary outcomes were the rate of en bloc (complete) resection and perforation during the procedure, and the total amount of solution injected.

RESULTS

All esophageal ESDs were completed. The median dissection time was significantly shorter for the ESD-T group (median 12.5 min, interquartile range 10.2-14.5) when comparing to the ESD-N group (median 18.0 min, interquartile range 14.6-19.2) (P=0.040). The en bloc resection rate was 100% in both groups, with a rate of complete resection of 87.5% and a rate of perforation of 37.5% for both groups. The median amount of solution injected was not significantly different between the ESD-T (18.0 ml) and ESD-N (20.5 ml) groups (P=0.526).

CONCLUSION

Clip-with-thread traction improved the performance of ESD for lesions with submucosal fibrosis. However, the method might not reduce the risk of perforation, which remains an important clinical issue to resolve.

Risk Factors for Esophageal Fistula in Esophageal Cancer Patients Treated with Radiotherapy: A Systematic Review and Meta-Analysis

<b><i>Objective:</i></b> Esophageal fistula is a critical and fatal complication of esophageal cancer. The aim of this meta-analysis was to explore the risk factors for esophageal perforation in esophageal cancer patients treated with radiotherapy. <b><i>Methods:</i></b> Data from the PubMed and Embase databases were retrieved for clinical research published between 1990 and 2018. The Newcastle-Ottawa Scale was used to evaluate the quality of the articles. A meta-analysis was performed using the RevMan 5.3 software provided by the Cochrane Collaboration Network. <b><i>Results:</i></b> Seventeen articles were eligible for the meta-analysis. In these articles, over 35 risk factors for esophageal fistula formation were described and 17 risk factors were analyzed. Significant differences in the odds of developing an esophageal perforation were found with regard to age (OR 2.34, 95% CI 1.08–5.03, <i>p</i> = 0.001), ulcerative type (OR 2.72, 95% CI 1.43–5.16, <i>p</i> = 0.002), histology (OR 4.16, 95% CI 1.14–15.12, <i>p</i> = 0.03), T stage (OR 2.66, 95% CI 1.44–4.91, <i>p</i> = 0.002), short-term response (OR 2.21, 95% CI 1.06–4.62, <i>p</i> = 0.03), chemotherapy regimen (OR 2.80, 95% CI 1.38–5.68, <i>p</i> = 0.005), and stenosis (OR 2.00, 95% CI 1.03–3.89, <i>p</i> = 0.04). <b><i>Conclusions:</i></b> An age of &#x3c;60–65 years, ulcerative type, squamous cell cancer, T4 stage, incomplete response, fluorouracil-based regimen, and stenosis were associated with an increased risk of esophageal fistula during or after radiotherapy. However, further, large-scale prospective studies are needed to establish the validity of this associ­ation.

Development and validation of a risk prediction model for radiotherapy-related esophageal fistula in esophageal cancer

Objectives

We aimed to identify the risk factors and provide a nomogram for the prediction of radiotherapy-related esophageal fistula in patients with esophageal cancer (EC) using a case-control study.

Patients and methods

Patients with esophageal fistula who received radiotherapy or chemoradiotherapy between 2003 and 2017 were retrospectively collected in two institutions. In the training cohort (TC), clinical, pathologic, and serum data of 136 patients (cases) who developed esophageal fistula during or after radiotherapy were enrolled and compared with 272 controls (1:2 matched with the diagnosis time of EC, sex, marriage, and race). After the univariable and multivariable logistic regression analyses, the independent risk factors were identified and incorporated into a nomogram. Then the nomogram for the risk prediction was externally validated in the validation cohort (VC; 47 cases and 94 controls) using bootstrap resampling.

Results

Multivariable analyses demonstrated that ECOG PS, BMI, T4, N2/3 and re-radiotherapy were independent factors for esophageal fistula. Then a nomogram was constructed with the C-index of 0.805 (95% CI, 0.762–0.848) for predicting the risk of developing esophageal fistula in EC patients receiving radiotherapy. Importantly, the C-index maintained 0.764 (95% CI, 0.683–0.845) after the external validation.

Conclusions

We created and externally validated the first risk nomogram of esophageal fistula associated with radiotherapy. This will aid individual risk stratification of patients with EC developing esophageal fistula.

Outcome of delayed versus timely esophagectomy after chemoradiation for esophageal adenocarcinoma

BACKGROUND

Salvage and delayed esophagectomy after chemoradiation therapy (CRT) have been associated with increased morbidity and mortality, but recent series have shown similar outcomes compared to timely esophagectomy. We aim to evaluate outcomes for delayed and salvage esophagectomy for esophageal adenocarcinoma utilizing a large national database.

METHODS

The National Cancer Database for 2004 to 2014 was queried for patients with clinical stage II or III esophageal adenocarcinoma who underwent preoperative CRT and esophagectomy. Patients who underwent surgery <90 days after CRT were defined as the timely esophagectomy group (n = 7822), and those who underwent surgery ≥90 days after CRT were defined as the delayed esophagectomy group (n = 667).

RESULTS

A total of 8489 patients met our inclusion criteria. The median post-CRT interval was 49 days (range, 40-61 days) for the timely esophagectomy group and 109 days (range, 97-132 days) for the delayed esophagectomy group. The delayed group was more likely to be of black race (2.3% vs 1.2%; P < .01) and more likely to have Medicare (47.9% vs 39.8%; P < .001). There were no significant between-group differences in chemotherapy regimens (P = .17), radiation dose (P = .18), or surgical approach (P = .48). The delayed esophagectomy group had higher rates of pathological complete response (22.2% vs 18.6%; P = .043) and 90-day postoperative mortality (10.4% vs 7.8%; P < .01). On multivariate analysis, delayed esophagectomy was not independently associated with decreased overall survival.

CONCLUSIONS

In this large retrospective database study, despite increased perioperative mortality, delayed and salvage esophagectomy for adenocarcinoma appear to have similar long-term survival as timely esophagectomy. Delayed and salvage esophagectomy may be offered to patients who do not receive timely esophagectomy after CRT.

Gross tumor volume is an independent prognostic factor in patients with postoperative locoregional recurrence of esophageal squamous cell carcinoma

Many cases of esophageal squamous cell carcinoma (ESCC) involve lymph node and distant metastases after esophagectomy, and most patients relapse within 2 years. Intensity-modulated radiotherapy (IMRT) is an important treatment for these cases of recurrence in ESCC and is widely used in clinical practice. A retrospective study of 137 postoperative patients with locoregional recurrences of ESCC who received IMRT was carried out. Kaplan-Meier survival curves and log-rank tests of univariate analysis was performed to assess whether there was a significant association between demographic and clinical features and death after recurrence. For multivariate analysis, the statistically significant results from the Kaplan-Meier method were subjected to Cox regression analysis. A total of 109 male and 28 female patients were included. There were 21 (15.3%), 58 (42.3%), 36 (26.3%), 3 (2.2%), 17 (12.4%), and 2 (1.5%) recurrences in the anastomotic, supraclavicular, mediastinal, tumor bed, polyregional, and abdominal regions, respectively. Univariate analysis showed that the gross tumor volume (GTV) of radiation (<27 vs. ≥27 cm³) and the number of lymph nodes were significantly associated with survival. The survival rates of patients at 1, 2, 3 and 5 years with GTV<27 cm³ were 72.7, 51.5, 37.1 and 25.9%, respectively, and with GTV≥27 cm³ were 63.7, 26.9, 17.9 and 0%, respectively. The significant independent prognostic factor was GTV [<27 vs. ≥27 cm³; hazard ratio (HR), 1.746; 95% confidence interval (CI), 1.112–2.741]. In conclusion, GTV of radiation (<27 vs. ≥27 cm³) is an independent factor in predicting locoregional recurrence after ESCC. Patients with GTV<27 cm³ are likely to have a better prognosis.

CONVERSION THERAPY FOR GASTRIC CANCER: EXPANDING THE TREATMENT POSSIBILITIES

BACKGROUND

Conversion therapy in gastric cancer (GC) is defined as the use of chemotherapy/radiotherapy followed by surgical resection with curative intent of a tumor that was prior considered unresectable or oncologically incurable.

AIM

To evaluate the results of conversion therapy in the treatment of GC.

METHODS

Retrospective analysis of all GC surgeries between 2009 and 2018. Patients who received any therapy before surgery were further identified to define the conversion group.

RESULTS

Out of 1003 surgeries performed for GC, 113 cases underwent neoadjuvant treatment and 16 (1.6%) were considered as conversion therapy. The main indication for treatment was: T4b lesions (n=10), lymph node metastasis (n=4), peritoneal carcinomatosis and hepatic metastasis in one case each. The diagnosis was made by imaging in 14 cases (75%) and during surgical procedure in four (25%). The most commonly used chemotherapy regimens were XP and mFLOX. Major surgical complications occurred in four cases (25%) and one (6.3%) died. After an average follow-up of 20 months, 11 patients (68.7%) had recurrence and nine (56.3%) died. Prolonged recurrence-free survival over 40 months occurred in two cases.

CONCLUSION

Conversion therapy may offer the possibility of prolonged survival for a group of GC patients initially considered beyond therapeutic possibility.

Prognostic Factors and Appropriate Lymph Node Dissection in Salvage Esophagectomy for Locally Advanced T4 Esophageal Cancer

BACKGROUND

A suitable treatment strategy for esophageal cancer after definitive chemoradiotherapy for T4 cases has not been established and remains unclear. This study aimed to clarify the independent prognostic factors, surgical indications, and optimal extent of lymphadenectomy for T4 esophageal cancer.

METHODS

Of 803 patients who underwent esophagectomy for esophageal cancer at the authors' institution from 2006 to March 2018, the study included 33 patients who underwent salvage esophagectomy with locally advanced T4 cancer. The study examined the baseline attributes and treatment results of these cases and evaluated the prognostic factors and treatment strategies.

RESULTS

The independent favorable prognostic factors in T4 cancer (T4a/T4b = 11/22) included non-T4b status [hazard ratio (HR), 15.311; 95% confidence-interval (CI), 1.277-183.5] and R0 resection (HR, 14.706; 95% CI, 1.193-166.67). For the cases in which R0 resection was possible (n = 14), both the 1- and 5-year survival rates were 90.9%, whereas for the cases without R0 dissection (n = 19), the 1- and 5-year survival rates were respectively 44.9% and 0%. In the univariate analysis, the patients who underwent two- or three-field lymph node dissection tended to have a better prognosis (p = 0.062), and those with 60 or more lymph nodes dissected had a significantly better prognosis (p = 0.038). For the patients who underwent salvage esophagectomy with typical lymph node dissection, the rate of complications classified as Clavien-Dindo grade 3 or higher (33.3%) was not increased, indicating that the procedure was relatively safe.

CONCLUSIONS

The results showed that in salvage esophagectomy for T4 esophageal cancer, R0 resection led to improved prognosis. Because typical two- or three-field lymph node dissection including prophylactic dissection could be performed safely and led to a better prognosis in salvage esophagectomy, typical esophagectomy including prophylactic lymph node dissection should be performed if possible.

Postoperative Pneumonia is Associated with Long-Term Oncologic Outcomes of Definitive Chemoradiotherapy Followed by Salvage Esophagectomy for Esophageal Cancer

BACKGROUND OR PURPOSE

As we previously indicated, postoperative pneumonia has a negative impact on the overall survival after planned esophagectomy. However, the impact of postoperative pneumonia after salvage esophagectomy on long-term oncologic outcomes still remains unclear. This study aimed to indicate the association between postoperative pneumonia and long-term outcomes of definitive chemoradiotherapy followed by salvage esophagectomy. Furthermore, we determined a prediction model for overall survival (OS) and disease-free survival (DFS) using a survival classification and regression tree (CART).

METHODS

Ninety-three patients who underwent CRT followed by esophagectomy for thoracic esophageal cancer were identified for this study. Forty-nine patients and 44 patients were included in the salvage and neoadjuvant groups, respectively. We investigated the association between postoperative pneumonia and long-term oncologic outcomes following salvage esophagectomy.

RESULTS

Patients from the salvage group tended to have a lower OS compared to neoadjuvant group (median survival: salvage, 24 months vs neoadjuvant, 43 months, p = 0.117). Multivariate analyses revealed that postoperative pneumonia adversely affected both OS (p < 0.001) and DFS (p = 0.044) after salvage esophagectomy. We generated the prediction model for OS and DFS in the salvage group using survival CART. Postoperative pneumonia was the most important parameter for predicting the OS.

DISCUSSION

The present study demonstrates the long-term outcomes and risk factors for mortality of salvage esophagectomy. To improve OS after salvage surgery, the development of a means of decreasing pulmonary complications is needed.

Clinicopathological examination of ESD as salvage therapy for esophageal cancer after definitive chemo-radiation therapy

BACKGROUND AND STUDY AIMS

 Salvage therapy for esophageal cancer following chemo-radiation therapy (CRT) has not been established. We aimed to evaluate endoscopic submucosal dissection (ESD) as a salvage therapy based on histopathological features of lesions.

PATIENTS AND METHODS

 We compared 10 lesions in eight patients with local residual, recurrent, or metachronous esophageal squamous cell carcinoma treated by ESD after CRT (CRT group) and 59 lesions treated by ESD without CRT (non-CRT group) during the same period.

RESULTS

 The en bloc resection rate was 100 % while the complete resection rate was 80.0 % in the lesions after CRT, indicating no difference between the CRT and non-CRT groups. Pathological examination showed that fibrosis was more intense in the lamina propria mucosa, muscularis mucosa, and submucosa. The muscularis mucosa was thicker in both non-tumor and tumor sites in the CRT group compared to the non-CRT group. However, severe submucosal fibrosis was observed only in one lesion in the CRT group. The maximum diameter of the submucosal artery was significantly larger in the CRT group ( P  < 0.001).

CONCLUSIONS

 Compared to the non-CRT group, the lesions in the CRT group were accompanied by fibrosis while the muscularis mucosa were thicker; however, severe fibrosis of the submucosa was rare. It is important to dissect the muscularis mucosa appropriately during ESD, which makes successful dissection of the submucosa possible. Attention should be paid to bleeding from large arteries.

Salvage Surgery for Esophageal Cancer: How to Improve Outcomes?

BACKGROUND

Locoregional recurrence rates after definitive chemoradiotherapy (dCRT) for locally advanced esophageal cancer (EC) are high. Salvage surgery (SALV) is considered the best treatment option in case of persistent or recurrent disease for operable patients, but SALV has been associated with increased morbidity and mortality. The aim of this study is to identify factors linked to outcomes after SALV to better select candidates and to optimize perioperative care.

STUDY DESIGN

We retrospectively analyzed data from 308 consecutive SALV patients from a large multicenter European cohort. Univariate and multivariate analyses were performed to identify factors associated with in-hospital postoperative morbidity, anastomotic leakage (AL), and overall survival (OS).

RESULTS

The in-hospital postoperative mortality and morbidity rates were 8.4 and 34.7%, respectively. Squamous cell histology (p = 0.040) and radiation dose ≥ 55 Gy (p = 0.047) were independently associated with major morbidity. The AL rate was 12.7%, and cervical anastomosis was independently associated with AL (p = 0.002). OS at 5 years was 34.0%. Radiation dose ≥ 55 Gy (p = 0.003), occurrence of postoperative complications (p = 0.006), ypTNM stage 3 (p = 0.019), and positive surgical margins (p < 0.001) were linked to poor prognosis.

CONCLUSIONS

SALV is a valuable option for patients with persistent or recurrent disease after dCRT and offers long-term survival. Factors such as radiation dose and anastomosis location identified here will help to optimize outcomes after SALV, which may be considered a standard treatment in the EC therapeutic armamentarium.

Salvage esophagectomy with pancreatectomy for local recurrence of thoracic esophageal cancer after definitive chemoradiotherapy: A case report

•

Very little article in literature has been reported the outcome of esophageal cancer patients who underwent esophagectomy with pancreatectomy.

•

We describe a case of thoracic esophageal cancer in which a relapse occurred in the early postoperative phase, although R0 resection was accomplished by salvage esophagectomy with pancreatectomy.

•

Because the risk of postoperative complications and relapse is high in patients with advanced esophageal cancer undergoing esophagectomy with pancreatectomy, the applicability of surgery needs to be carefully considered.

Introduction

We encountered a case of advanced thoracic esophageal cancer in which R0 resection was achieved by salvage esophagectomy with pancreatectomy, but relapse occurred in the early postoperative phase.

Presentation of case

A 64-year-old man with lower intrathoracic esophageal cancer received chemoradiotherapy, and a complete response was achieved. Subsequently, however, lymph node relapse, with infiltration into the pancreas, was observed. Thus, subtotal esophageal resection, total gastrectomy, distal pancreatectomy, and splenectomy were performed. Hepatic relapse occurred 7 months after the surgery, and the patient died 18 months after the surgery.

Discussion

The surgical risk of salvage surgery is considered to be extremely high, however selected patients may benefit from highly invasive procedures. In this case, despite R0 resection was achieved by salvage esophagectomy with pancreatectomy, a relapse occurred in the early postoperative phase. The treatment outcome of esophageal cancer patients with infiltration into the pancreas was not favorable.

Conclusions

Because the risk of postoperative complications and relapse is high in patients with advanced esophageal cancer undergoing esophagectomy with pancreatectomy, the applicability of surgery needs to be carefully considered.

Prognostic impact of postoperative pulmonary complications following salvage esophagectomy after definitive chemoradiotherapy

BACKGROUND

Postoperative complications after esophagectomy for esophageal cancer have a negative effect on patients' survival. Although postoperative complications are more frequently observed after salvage esophagectomy than after planned esophagectomy, the effects of postoperative complications on long-term oncologic outcomes after salvage esophagectomy remain unclear.

METHODS

This retrospective study of 70 esophageal cancer patients after definitive chemoradiotherapy (dCRT) compared long-term outcomes between those with and without complications. The association between morbidity and overall survival (OS) was evaluated by a Cox regression analysis. To identify the risk factors for pulmonary complications, logistic regression analysis was carried out.

RESULTS

Postoperative complications occurred in 42 (60.0%) patients. Pulmonary complications and anastomotic leakage occurred in 23 (32.9%) and 9 (12.9%) patients, respectively. Overall complications and anastomotic leakage did not affect long-term outcomes. Survival was significantly worse for patients with pulmonary complications. Radiation dose (<60 Gy), response to dCRT (complete), ypStage (0-II), residual disease (R0), and pulmonary complications (negative) were independent factors related to a favorable OS. BMI (<20 kg/m² ), ASA-PS (2-3), and radiation dose (>60 Gy) were significant factors affecting the occurrence of pulmonary complications.

CONCLUSIONS

Development of postoperative pulmonary complications was independently associated with poor prognosis in patients who underwent salvage esophagectomy after dCRT.

Comparison between neoadjuvant chemotherapy followed by surgery and definitive chemoradiotherapy for overall survival in patients with clinical Stage II/III esophageal squamous cell carcinoma (JCOG1406-A)

Background

Neoadjuvant chemotherapy followed by surgery (NAC-S) represents the standard treatment for patients with Stage II/III esophageal squamous cell carcinoma (ESCC) in Japan. Chemoradiotherapy (CRT) is performed in patients who refuse or have contraindications to surgery. However, randomized clinical trials that compare NAC-S with CRT have not been conducted. The aim of this study was to explore subgroups of patients undergoing CRT to identify those with survival outcomes potentially equivalent to NAC-S.

Methods

Pooled data from two clinical trials in patients with Stage II/III ESCC, the JCOG9907 trial and the JCOG9906 trial were used. JCOG9907 demonstrated that NAC-S resulted in superior overall survival (OS) compared with surgery followed by adjuvant chemotherapy. JCOG9906 was a single-arm trial that explored the efficacy and safety of CRT. The eligibility criteria in the two trials were almost identical. Subgroup analyses of clinical data (serum albumin, cT, cN, cstage and tumor location) were conducted with Cox proportional hazards regression models for patients assigned to receive NAC-S in JCOG9907 and patients in JCOG9906.

Results

The analysis comprised 163 patients from JCOG9907 in NAC-S arm (NAC-S group) and 73 patients from JCOG9906 who received CRT (CRT group). Baseline characteristics were similar between the two groups. OS was better in the NAC-S group than the CRT group (adjusted hazard ratio 1.72; 95% confidence interval 1.19-2.50). All subgroups in the NAC-S group had longer OS compared with those in the CRT group.

Conclusions

OS was superior after NAC-S rather than CRT. None of the CRT subgroups had similar OS to the NAC-S groups.

Salvage esophagectomy: safe therapeutic strategy?

The objectives of this review were to assess both the short- and long-term clinical outcomes in patients managed with definitive chemoradiotherapy, and salvage esophagectomy subsequently in comparison to those neoadjuvant chemoradiotherapy followed by planned esophagectomy (NCRS) for esophageal cancer from published literature. Eleven studies comprising 1,906 patients were included, 563 in the salvage group and 1,343 in the NCRS group. Pooled analysis showed no significant difference between salvage and NCRS groups in overall survival [hazard ratio (HR) =1.17; 95% confidence interval (95% CI), 0.94-1.46, P=0.148], postoperative mortality [pooled odds ratios (POR) =1.12; 95% CI, 0.52-2.41, P=0.775], pulmonary complications (POR =1.24; 95% CI, 0.83-1.86, P=0.292) and positive resection margin incidence (POR =1.29; 95% CI, 0.94-1.76, P=0.114). However, within the salvage group there were increases in postoperative morbidity (POR =1.30; 95% CI, 1.00-1.67, P=0.046) and anastomotic leak (POR =1.88; 95% CI, 1.41-2.51, P<0.001). Herein we found that salvage esophagectomy has similar short- and long-term mortality in comparison to planned esophagectomy following neoadjuvant chemoradiotherapy. However, anastomotic leak is increased following salvage esophagectomy suggesting the need for this practice to be reserved for high volume surgeons within high volume centers.

Salvage esophagectomy for persistent or recurrent disease after definitive chemoradiation

Locoregionally advanced esophageal cancer is treated by some oncologists with definitive chemoradiation. The optimal strategy to treat persistent or recurrent disease after definitive chemoradiation is controversial. We reviewed the literature to determine current treatment options and optimal approaches. Salvage esophagectomy of relapsed or recurrent esophageal cancer has traditionally been associated with increased risk. Modern literature, however, suggests that in specialized high volume centers the risk of salvage esophagectomy when accompanied with various risk-reducing approaches (anastomosis in non-radiated esophagus, omental transposition, selective use of alternative conduits and two stage procedures) is similar to planned esophagectomy after neoadjuvant chemoradiation. Long-term survival rates following salvage esophagectomy are also achievable and similar to planned esophagectomy. Since there are no other potentially curable treatment options, we recommend that all physiologically fit patients with locoregionally persistent or recurrent esophageal cancer after definitive chemoradiation be referred to a specialized high volume esophageal center for salvage esophagectomy.

Salvage esophagectomy after failure of definitive radiochemotherapy for esophageal cancer

BACKGROUND

Definitive radiochemotherapy (dRCT) in locally advanced esophageal cancer is associated with a high rate of loco-regional recurrence. In this condition, salvage esophagectomy may be considered as a therapeutic option. The aim of this analysis is to evaluate the feasibility and the morbi-mortality of this strategy.

METHODS

Between January 2006 and April 2014, 208 patients underwent esophagectomy for esophageal cancer at ULB-Erasme-Bordet. Thirty-two patients received a preoperative radiochemotherapy (pRCT) followed by planned esophagectomy (Group 1) for locally advanced disease. Sixteen patients underwent salvage esophagectomy for recurrence or failure after dRCT (Group 2). Data on post-operative morbidity and mortality and survival were collected and analyzed.

RESULTS

An increase of overall morbidity was detected in Group 2 as compared to Group 1 (43% vs. 37.5%), mainly related to respiratory complications (35.5% vs. 28%) and anastomotic leak (25% vs. 3%). No 90-days mortality was observed in the two surgical groups. The 1, 2, and 3-year survival rates after surgery were respectively 89%, 80%, and 71% for Group1 and 84%, 73%, and 63% for Group 2.

CONCLUSIONS

In our experience, both salvage esophagectomy and esophagectomy after pRCT showed good survival results with low postoperative morbidity and mortality. Salvage surgery remains a therapeutic indication in selected patients. J. Surg. Oncol. 2016;114:833-837. © 2016 2016 Wiley Periodicals, Inc.

Systematic review and meta-analysis on the significance of salvage esophagectomy for persistent or recurrent esophageal squamous cell carcinoma after definitive chemoradiotherapy

The therapeutic strategy to be recommended in case of recurrent or persistent squamous cell esophageal cancer after completed definitive chemoradiotherapy (dCRT) has to be documented. Salvage esophagectomy has traditionally been recognized as a viable option, but many clinicians oppose the use of surgery due to the associated excessive morbidity and mortality. 'Second-line' chemoradiotherapy (CRT) without surgery may offer a treatment alternative in these difficult and demanding clinical situations. Until now, no comprehensive attempt has been carried out to compare the respective therapeutic options. A systematic literature search was performed focusing on studies comparing survival and treatment-related mortality in patients submitted to salvage esophagectomy or second-line CRT for recurrent or persistent esophageal squamous cell carcinoma after dCRT. Hazard ratios and risk ratios were calculated to compare the effect of these therapeutic strategies on overall survival and treatment-related mortality, respectively. Four studies containing 219 patients, with persistent or recurrent esophageal squamous cell carcinoma after dCRT, were included in the meta-analysis. The analysis revealed an overall survival benefit following salvage esophagectomy with a pooled hazard ratio for death of 0.42 (95% confidence interval 0.21-0.86, P = 0.017) compared with second-line CRT. A treatment-related mortality of 10.3% was recorded in the 36 patients who were submitted to salvage esophagectomy, while it was impossible to perform a meta-analysis comparing treatment-related mortality between the groups. Salvage esophagectomy offers significant gain in long-term survival compared with second-line CRT, although the surgery is potentially at a price of a high treatment-related mortality.

Prognostic factors for salvage endoscopic resection for esophageal squamous cell carcinoma after chemoradiotherapy or radiotherapy alone

BACKGROUND AND STUDY AIMS

Endoscopic resection is one treatment option for residual or locally recurrent esophageal cancer after definitive chemoradiotherapy or radiotherapy alone. However, little is known about the clinical benefit of salvage endoscopic resection for these lesions. Therefore, the effectiveness and prognostic factors of salvage endoscopic resection were investigated.

PATIENTS AND METHODS

A total of 37 patients with esophageal squamous cell carcinoma (SCC) who underwent salvage endoscopic resection after definitive chemoradiotherapy or radiotherapy alone were reviewed. The method of salvage endoscopic resection was endoscopic mucosal resection using a cap (EMR-C), strip biopsy, or endoscopic submucosal dissection. The effectiveness and prognostic factors of salvage endoscopic resection were retrospectively analyzed.

RESULTS

A total of 37 patients with 49 lesions underwent salvage endoscopic resection. Baseline clinical stages were I in 23 patients, II in 3 patients, III in 9 patients, and IV in 2 patients. The number of locoregional recurrences and residual lesions were 35 and 14, respectively. The curative en bloc resection rate was 53.1 % (26/49). The total incidence of complications was 18.9 % (7/37); all were successfully managed conservatively. The 3-year and 5-year overall survival rates were 72.9 % and 53.3 %, respectively, with a median follow-up period of 54 months. Baseline clinical T1 - 2 and N0 were significant factors for good prognosis in terms of overall survival on univariate analysis.

CONCLUSIONS

Salvage endoscopic resection, especially EMR-C, is a safe and feasible procedure to control residual or recurrent superficial esophageal SCC after definitive chemoradiotherapy or radiotherapy alone. The present results showed that baseline clinical T1 - 2 and N0 before chemoradiotherapy or radiotherapy were significant prognostic factors.

Chemoradiotherapy for esophageal squamous cell cancer

Chemoradiotherapy has been clinically indicated for patients with resectable esophageal squamous cell carcinoma who refuse surgical resection and in locally advanced unresectable esophageal squamous cell carcinoma patients. Concurrent chemoradiotherapy prolongs survival than radiation therapy alone when given as definitive treatment. Therefore, chemoradiotherapy is recognized as the standard non-invasive treatment for patients with localized esophageal cancer who opt for non-surgical treatment. JCOG9906 showed promising outcomes for stage II/III ESCC patients. But there are some problems about chemoradiotherapy for esophageal squamous cell carcinoma. Late toxicities are sometimes lethal for patients who achieved complete response even after years. Salvage treatment for residual or recurrent disease is unestablished. Modified Radiation Therapy Oncology Group regimen at the dose of 50.4 Gy reduced late toxicities without reducing efficacy. Optimal timings and procedure of salvage surgery and endoscopic therapy is evaluated in JCOG0909. Strategy including salvage therapy after chemoradiotherapy should be considered at the time of starting the treatment. Targeted therapy has not shown adding effect for chemoradiotherapy for esophageal squamous cell carcinoma yet. New agents, such as immune checkpoint inhibitors, are expected to show synergistic effect with chemoradiotherapy for esophageal squamous cell carcinoma. Further investigation is needed.

A prospective, multicenter phase I/II study of induction chemotherapy with docetaxel, cisplatin and fluorouracil (DCF) followed by chemoradiotherapy in patients with unresectable locally advanced esophageal carcinoma

Purpose

Standard care for unresectable locally advanced esophageal squamous cell carcinoma (ESCC) is concurrent chemoradiotherapy, but survival remains limited. Neoadjuvant chemotherapy with docetaxel, cisplatin and fluorouracil (DCF) has demonstrated promising activity, with a pathological complete response (CR) of 17 % for resectable stage II/III ESCC. Here, we conducted a multicenter study to assess the efficacy and safety of induction chemotherapy with DCF followed by CRT in patients with unresectable locally advanced ESCC.

Methods

Eligibility criteria included clinical T4 and/or M1 lymph node ESCC, PS 0–1 and age 20–70 years. Treatment consisted of docetaxel 70 mg/m² and cisplatin 70 mg/m² on day 1, and fluorouracil 750 mg/m² on days 1–5, repeated every 3 weeks for three cycles, followed by cisplatin 70 mg/m² on days 64 and 92, and fluorouracil 700 mg/m² on days 64–67 and 92–95, concurrently with radiotherapy (60 Gy in 30 fractions, 5 days/week). Primary endpoint of the phase II part was CR rate.

Results

Thirty-three patients were enrolled. The completion rate of protocol treatment was 88 %. Thirteen patients (39.4 %) achieved a CR. With a median follow-up period of 41 months (range 24–49 months), median progression-free survival was 12.2 months, and median survival was 26.0 months, with a survival rate of 40.4 % at 3 years. The most common grade 3 or 4 toxicities were neutropenia, leukopenia, anorexia and dysphagia. No treatment-related death was observed.

Conclusion

Induction chemotherapy with DCF followed by CRT is tolerable and shows promising efficacy for unresectable locally advanced ESCC.

Salvage endoscopic resection as a treatment for locoregional failure or recurrence following chemoradiotherapy or radiotherapy for esophageal cancer

Radiotherapy (RT) or chemoradiotherapy (CRT) is a potentially curative, non-surgical treatment option for esophageal cancer, although the rate of local failure within the esophagus remains relatively high. Salvage esophagectomy is not regarded as a common treatment for esophageal cancer, since it is a high-risk surgery with a relatively high surgical mortality rate. Salvage endoscopic resection (ER) for local failure is used for treatment when esophageal cancer is localized and superficial. To evaluate to usefulness of salvage ER, the present study reviewed the clinicopathological records and follow-up data of 37 patients that underwent salvage ER for esophageal cancer, following initial treatment with RT or CRT. Salvage ER was conducted on a total of 78 lesions observed in the 37 patients. Since a thick epithelium and lack of normal vessels on the surface of the mucosa are characteristics of esophageal mucosa following RT or CRT, almost all the lesions were detected using iodine dyeing, and not by narrow band imaging. The growth rate of the detected lesions was relatively high, and early treatment was required. No particular complications occurred during the endoscopic treatment. A total of 11 patients survived for >5 years subsequent to initial endoscopic treatment. Only 4 patients succumbed to esophageal cancer. In conclusion, the present study demonstrated that salvage ER following CRT or RT for esophageal cancer is a minimally invasive, safe, adaptive and curative method for superficial lesions without distant metastases in patients with esophageal cancer with local failure following CRT or RT.

Is conversion therapy possible in stage IV gastric cancer: the proposal of new biological categories of classification

Conversion therapy for gastric cancer (GC) has been the subject of much recent attention. It is defined as a surgical treatment aiming at an R0 resection after chemotherapy for tumors that were originally unresectable or marginally resectable for technical and/or oncological reasons. However, the indications for resection remain to be clarified. In the present review, we focus on the biology and heterogeneous characteristics of stage IV GC and propose new categories of classification. Stage IV GC patients can be divided based on the absence (categories 1 and 2) or presence (categories 3 and 4) of macroscopically detectable peritoneal dissemination, which has a different biological outcome compared to hematological metastasis. Category 1 is defined oncologically as stage IV but the metastasis is technically resectable. Category 2 includes a marginally resectable metastasis or patients for whom the operation would not necessarily be the best choice. Category 3 includes a potentially unresectable metastasis of peritoneal dissemination that is only macroscopically detectable. Category 4 includes noncurable metastasis with peritoneal and other organ metastasis. The indications for conversion therapy might include the patients from category 2, some patients from category 3 and a very small number of patients from category 4. The longer survival can be expected for patients corresponding to categories 1, 2 and, to a lesser extent, 3, while the treatment of other patients focuses on "care." The provision of conversion therapy for stage IV GC patients might be one of the main roles of surgical oncologists in the near future.

Salvage Surgery After Chemoradiotherapy in the Management of Esophageal Cancer: Is It a Viable Therapeutic Option?

PURPOSE

The aim of this large multicenter study was to assess the impact of salvage esophagectomy after definitive chemoradiotherapy (SALV) on clinical outcome.

PATIENTS AND METHODS

Data from consecutive adult patients undergoing resection for esophageal cancer in 30 European centers from 2000 to 2010 were collected. First, groups undergoing SALV (n = 308) and neoadjuvant chemoradiotherapy followed by planned esophagectomy (NCRS; n = 540) were compared. Second, patients who benefited from SALV for persistent (n = 234) versus recurrent disease (n = 74) were compared. Propensity score matching and multivariable analyses were used to compensate for differences in some baseline characteristics.

RESULTS

SALV versus NCRS groups: In-hospital mortality was similar in both groups (8.4% v 9.3%). The only significant differences in complications were seen for anastomotic leak (17.2% v 10.7%; P = .007) and surgical site infection, which were both more frequent in the SALV group. At 3 years, groups had similar overall (43.3% v 40.1%; P = .542) and disease-free survival (39.2% v 32.8%; P = .232) after matching, along with a similar recurrence pattern. Persistent versus recurrent disease groups: There were no significant differences between groups in incidence of in-hospital mortality or major complications. At 3 years, overall (40.9% v 56.2%; P = .046) and disease-free survival (36.6% v 51.6%; P = .095) were lower in the persistent disease group.

CONCLUSION

The results of this large multicenter study from the modern era suggest that SALV can offer acceptable short- and long-term outcomes in selected patients at experienced centers. Persistent cancer after definitive chemoradiotherapy seems to be more biologically aggressive, with poorer survival compared with recurrent cancer.

Salvage high-dose-rate brachytherapy for esophageal cancer in previously irradiated patients: A retrospective analysis

PURPOSE

To evaluate outcomes after exclusive salvage high-dose-rate (HDR) intraluminal esophageal brachytherapy given to previously irradiated patients with recurrent esophageal cancer.

METHODS AND MATERIALS

We reviewed medical records of 30 patients who were treated by salvage HDR brachytherapy for local esophageal cancer. Brachytherapy delivered four to six fractions of 5-7 Gy at 5 mm from the applicator surface and 20 mm above and below the macroscopic tumor volume.

RESULTS

Eighty percentage of patients received treatment as initially planned. Complete response rate, evaluated 1 month after brachytherapy by endoscopy and biopsy, was 53%. Squamous histology and complete endoscopic tumor response at 1 month were significantly associated with better local tumor control. Median local progression-free survival was 9.8 months. Overall survival was 31.5% and 17.5% at 1 and 2 years, respectively. On univariate analysis, preserved performance status and limited weight loss (<10%) before salvage brachytherapy were associated with better overall survival. Severe toxicity (Grade ≥3) occurred in 7 patients (23%).

CONCLUSIONS

Although esophageal cancer in previously irradiated patients is associated with poor outcomes, HDR brachytherapy may be a valuable salvage treatment for inoperable patients with locally limited esophageal cancer, particularly in the subset of patients with preserved performance status and limited weight loss (≤10%) before salvage brachytherapy.

Salvage Esophagectomy After Definitive Chemoradiotherapy for Patients with Esophageal Squamous Cell Carcinoma: Who Really Benefits from this High-Risk Surgery?

PURPOSE

The aim of this study was to identify good candidates for salvage esophagectomy after definitive chemoradiotherapy (dCRT), based on safety and survival.

METHODS

Sixty-three patients who underwent salvage esophagectomy, after dCRT, at the Cancer Institute Hospital, Tokyo, Japan, between 1988 and 2013, were retrospectively analyzed. Short-term outcomes were evaluated by reviewing postoperative complications, length of postoperative hospital stay, and mortality. Survival rates were calculated using the Kaplan-Meier method, and statistical significance was determined using the log-rank test. The Cox proportional hazards model was used for univariate and multivariate analyses of overall survival. Univariate logistic regression analysis was used to identify factors related to R0 resection.

RESULTS

Postoperative complications occurred in 41 patients (65.1 %), and the mortality rate was 7.9 %. In-hospital deaths did not occur among patients with less advanced tumors prior to dCRT (cT1-2 and cN0), or among those who had previously achieved a complete response (CR); the 3- and 5-year overall survival rates were 29.8 % and 15.0 %, respectively. Univariate analysis revealed that residual disease, tumor depth, dCRT response, lymph node metastasis, and time to relapse were significant factors affecting overall survival. Multivariate analysis demonstrated that R0 resection and ypT0-2 tumors were significant, favorable prognostic factors in patients undergoing salvage esophagectomy. In addition, cT1-2 tumors, initially resectable tumors, ycT1-2 tumors, and relapse after CR were factors predicting R0 resection.

CONCLUSIONS

Based on both short- and long-term outcomes, patients with pretreatment or preoperative T1-2 tumors and those with relapse after CR are good candidates for salvage esophagectomy.

[Salvage surgery in esophageal cancer : Feasibility in patients after definitive radiochemotherapy (> 50 Gy)]

BACKGROUND

Salvage surgery as an additional therapy option is currently discussed for an increasing number of patients with esophageal cancer after definitive radio(chemo)therapy after tumor progression, recurrence or on explicit request of the patient.

OBJECTIVES

The objective of this study was an analysis of the surgical option of salvage esophagectomy after definitive radiation in patients with esophageal cancer. Additionally the current literature on this topic was evaluated.

MATERIAL AND METHODS

A total of 92 patients with esophageal cancer from a prospective database were included in this study who underwent esophagectomy either after neoadjuvant radio(chemo)therapy (< 50 Gy) or definitive radio(chemo)therapy (> 50 Gy) between 2002 and 2012. The analysis was performed retrospectively.

RESULTS

The median survival of the two groups of patients was not significantly different after initial diagnosis with 24.2 months (95 % CI 0.0-51.93) for patients undergoing definitive radio(chemo)therapy and 30.7 months (95 % CI 9.3-52.2) for patients after neoadjuvant therapy (p = 0.96). Both patient groups showed no differences in pretherapeutic characteristics and response to radio(chemo)therapy. Postoperative complications and perioperative mortality were not different.

DISCUSSION

Salvage esophagectomy is now an additional treatment option after definitive radio(chemo)therapy in patients with esophageal cancer. In preselected patients with tumor recurrence, progression or with a strong wish for surgical therapy, salvage surgery should be discussed in interdisciplinary tumor boards after exclusion of distant metastases.