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Petric J, Handshin S, Bright T, Watson DI. Planned oesophagectomy after chemoradiotherapy versus salvage oesophagectomy following definitive chemoradiotherapy: a systematic review and meta-analysis. ANZ J Surg 2022; 93:829-839. [PMID: 36582046 DOI: 10.1111/ans.18225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/05/2022] [Accepted: 12/11/2022] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Josipa Petric
- Department of Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Samuel Handshin
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Tim Bright
- Department of Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - David I Watson
- Department of Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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Higuchi T, Shoji Y, Koyanagi K, Tajima K, Kanamori K, Ogimi M, Yatabe K, Ninomiya Y, Yamamoto M, Kazuno A, Nabeshima K, Nakamura K. Multimodal Treatment Strategies to Improve the Prognosis of Locally Advanced Thoracic Esophageal Squamous Cell Carcinoma: A Narrative Review. Cancers (Basel) 2022; 15:cancers15010010. [PMID: 36612007 PMCID: PMC9817845 DOI: 10.3390/cancers15010010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/17/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022] Open
Abstract
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.
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Han W, Wang L, Li C, Chen J, Zhang W, Wang X, Pang Q, Zhao Y, Sun X, Zhang K, Li G, Li L, Qiao X, Liu M, Wang Y, Deng L, Wang W, Bi N, Zhang T, Deng W, Ni W, Chang X, Zhou Z, Liang J, Feng Q, Wang L, Chen D, Lv J, Zhu S, Han C, Xiao Z. Progression-free survival as surrogate endpoint of overall survival in esophageal squamous cell carcinoma: a real-world data and literature-based analysis. Ther Adv Med Oncol 2022; 14:17588359221131526. [PMID: 36324733 PMCID: PMC9619262 DOI: 10.1177/17588359221131526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 09/22/2022] [Indexed: 11/06/2022] Open
Abstract
Background The surrogacy of progression-free survival (PFS) for overall survival (OS) in esophageal squamous cell carcinoma (ESCC) remains unelucidated. This study aimed to determine the validity of PFS as a surrogate endpoint for OS in ESCC patients treated with definitive radiotherapy or definitive chemoradiotherapy (dRT/dCRT), as well as characterize the prognostic factors and survival of such patients. Methods A total of 3662 patients from 10 cancer centers were enrolled. One-, 2-, and 3-year PFS (PFS12, PFS24, and PSF36, respectively) were used as time points for analysis. At each time point, ESCC-specific mortality and OS were characterized using competing risk and conditional survival models, while correlation between PFS and OS was evaluated by linear regression. Results At PFS12, PFS24, and PFS36, a progressive decrease in 5-year ESCC-specific mortality (35.2%-13.4%) and increase in 5-year OS (46.6%-62.9%) were observed. Regardless, the OS of patients remained markedly lower than those of the age- and sex-matched Chinese general population. TNM stage remained a significant prognostic factor at PFS36. Strong correlation was found between 3-year PFS and 5-year OS, which was further externally validated. Conclusions Three-year PFS may act as a potential surrogate endpoint for 5-year OS. TNM stage was considered a significant prognostic factor for OS, and may represent the optimal prognostic tool to guide clinical decision-making and post-treatment follow-up.
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Affiliation(s)
| | | | - Chen Li
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital/National Clinical Research Center for Cancer, Tianjin, China
| | - Junqiang Chen
- Department of Radiation Oncology, Fujian Cancer Hospital/Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Wencheng Zhang
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital/National Clinical Research Center for Cancer, Tianjin, China
| | - Xin Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qingsong Pang
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital/National Clinical Research Center for Cancer, Tianjin, China
| | - Yidian Zhao
- Department of Radiation Oncology, Anyang Cancer Hospital, Anyang, China
| | - Xinchen Sun
- Department of Radiation Oncology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kaixian Zhang
- Department of Oncology, Tengzhou Central People’s Hospital, Tengzhou, China
| | - Gaofeng Li
- Department of Radiation Oncology, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Ling Li
- Department of Oncology, Tengzhou Central People’s Hospital, Tengzhou, China
| | - Xueying Qiao
- Department of Radiation Oncology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Miaoling Liu
- Department of Radiation Oncology, Affiliated Hospital of Hebei University, Baoding, China
| | - Yadi Wang
- Department of Radiation Oncology, PLA Army General Hospital, Beijing, China
| | - Lei Deng
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenqing Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Nan Bi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Zhang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Deng
- Department of Radiation Oncology, Peking University School of Oncology, Beijing Cancer Hospital and Beijing Institute for Cancer Research, Beijing, P.R. China
| | - Wenjie Ni
- Department of Radiation Oncology, Beijing Shijitan Hospital, Capital Medical University, Ninth School of Clinical Medicine, Peking University, School of Oncology, Capital Medical University, Beijing, P.R. China
| | - Xiao Chang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zongmei Zhou
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Liang
- Department of Radiation Oncology, Cancer Hospital Chinese Academy of Medical Sciences, Shenzhen Hospital, Shenzhen, China
| | - Qinfu Feng
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lvhua Wang
- Department of Radiation Oncology, Cancer Hospital Chinese Academy of Medical Sciences, Shenzhen Hospital, Shenzhen, China
| | - Dongfu Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jima Lv
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuchai Zhu
- Department of Radiation Oncology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chun Han
- Department of Radiation Oncology, The Fourth Hospital of Hebei Medical University, No.12, Health Road, Shijiazhuang, Hebei, China
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Miyata H, Sugimura K, Kanemura T, Takeoka T, Sugase T, Tanaka K, Makino T, Yamashita K, Yamasaki M, Motoori M, Shiraishi O, Kimura Y, Yasuda T, Yano M, Doki Y. Salvage Surgery for Recurrent Disease after Definitive Chemoradiotherapy for Esophageal Squamous Cell Carcinoma. Ann Surg Oncol 2022; 29:5657-5665. [PMID: 35536523 DOI: 10.1245/s10434-022-11802-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/05/2022] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Hiroshi Miyata
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan.
| | - Keijiro Sugimura
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Takashi Kanemura
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Tomohira Takeoka
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Takahito Sugase
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Koji Tanaka
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Tomoki Makino
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Kotaro Yamashita
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Makoto Yamasaki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Masaaki Motoori
- Department of Surgery, Osaka General Medical Center, Osaka, Japan
| | | | - Yutaka Kimura
- Department of Surgery, Kinki University, Osaka, Japan
| | | | - Masahiko Yano
- Department of Surgery, Osaka General Medical Center, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
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Kimura H, Yoshida M, Yabuuchi Y, Kakushima N, Yamamoto Y, Kawata N, Takizawa K, Kishida Y, Imai K, Ito S, Hotta K, Ishiwatari H, Matsubayashi H, Ono H. Long-term outcomes of salvage endoscopic submucosal dissection for local failure after chemoradiotherapy for esophageal squamous cell carcinoma. Jpn J Clin Oncol 2021; 51:1036-1043. [PMID: 33758950 DOI: 10.1093/jjco/hyab027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/13/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Salvage endoscopic submucosal dissection is considered a minimally invasive treatment for local failure after chemoradiotherapy for esophageal squamous cell carcinoma. However, the long-term outcomes have not been fully evaluated. This study investigated the short-term and long-term outcomes of salvage endoscopic submucosal dissection. METHODS Patients who underwent endoscopic submucosal dissection for local recurrence or residual tumor after chemoradiotherapy from January 2006 to December 2017 were retrospectively investigated. Follow-up included endoscopic examination and computed tomography at least once every 6 months after salvage endoscopic submucosal dissection. Risk factors for disease recurrence after salvage endoscopic submucosal dissection were assessed using the Cox hazards model. RESULTS A total of 30 patients (33 cases of esophageal squamous cell carcinoma: local recurrence, n = 27; residual tumor, n = 6) were included. The median endoscopic submucosal dissection procedure time was 40 min (interquartile range [IQR], 33-58.5 min). En bloc resection was achieved in 31 (94%) of 33 esophageal squamous cell carcinoma cases. One patient with intraoperative perforation did not require surgical intervention and recovered with conservative treatment. A total of 16 patients (53%) had disease recurrence at a median follow-up of 51 months (IQR, 33-81 months). The 3-year overall, disease-specific, recurrence-free and local recurrence-free survival rates were 75%, 82%, 58% and 90%, respectively. The positive vertical margin, submucosal invasion in the endoscopic submucosal dissection specimen and piecemeal resection were significantly associated with disease recurrence after salvage endoscopic submucosal dissection. CONCLUSIONS Salvage endoscopic submucosal dissection is a feasible treatment for local failure after chemoradiotherapy for esophageal squamous cell carcinoma with acceptable long-term outcomes. However, for cases with positive vertical margins and submucosal invasion in the endoscopic submucosal dissection specimen, salvage endoscopic submucosal dissection outcomes were insufficient and additional treatment might be required.
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Affiliation(s)
- Hidenori Kimura
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yohei Yabuuchi
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Naomi Kakushima
- Department of Gastroenterology & Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoichi Yamamoto
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Sayo Ito
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | | | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
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Zhou N, Mitchell KG, Corsini EM, Truong VTT, Antonoff MB, Mehran RJ, Rajaram R, Rice DC, Roth JA, Sepesi B, Swisher SG, Vaporciyan AA, Walsh GL, Ajani JA, Hofstetter WL. Analysis of trimodal and bimodal therapy in a selective-surgery paradigm for locally advanced oesophageal squamous cell carcinoma. Br J Surg 2021; 108:1207-1215. [PMID: 34095952 DOI: 10.1093/bjs/znab162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/14/2021] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- N Zhou
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - K G Mitchell
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - E M Corsini
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - V T T Truong
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Texas, USA
| | - M B Antonoff
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - R J Mehran
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - R Rajaram
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - D C Rice
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - J A Roth
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - B Sepesi
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - S G Swisher
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - A A Vaporciyan
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - G L Walsh
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - J A Ajani
- Department of Gastrointestinal Medical Oncology, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - W L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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It's not always too late: a case for minimally invasive salvage esophagectomy. Surg Endosc 2020; 35:4700-4711. [PMID: 32940794 DOI: 10.1007/s00464-020-07937-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 08/25/2020] [Indexed: 01/03/2023]
Abstract
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.
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8
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Okamura A, Hayami M, Kozuki R, Takahashi K, Toihata T, Imamura Y, Mine S, Watanabe M. Salvage esophagectomy for initially unresectable locally advanced T4 esophageal squamous cell carcinoma. Esophagus 2020; 17:59-66. [PMID: 31595397 DOI: 10.1007/s10388-019-00700-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 10/01/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Definitive chemoradiotherapy (dCRT) for esophageal squamous cell carcinoma (ESCC) is a potentially curative treatment modality, even for patients with unresectable T4 tumors. For patients who fail dCRT, salvage esophagectomy is known to be a high-risk procedure. However, the efficacy and safety of salvage surgery for these patients remain unclear. METHODS A total of 35 patients who underwent salvage esophagectomy after dCRT for initially unresectable locally advanced T4 ESCC were assessed, and both outcomes and prognostic factors after surgery were investigated. RESULTS Among the study population, R0 resection was achieved in 19 patients (54.3%). Postoperatively, 8 patients (22.9%) experienced Clavien-Dindo grade IIIb or higher complications, and 3 patients (8.6%) registered surgery-related mortality. Overall survival rates were 45.7%, 28.6%, and 5.7% at 1, 2, and 5 years, respectively. In Cox regression analysis, residual or relapsed tumor limited to T2 or less was an independent prognostic factor for better survival (P = 0.010). On the other hand, postoperative pneumonia and incomplete resection were negative prognostic factors (P < 0.001 and P = 0.019, respectively). Nodal involvement and extent of lymph node dissection did not impact patient survival. CONCLUSIONS Although salvage esophagectomy for initially unresectable T4 ESCC is considered a high-risk surgery with poor prognosis, long-term survival may be achieved in patients with ≤ T2 residual tumors. In addition, R0 resection and postoperative pneumonia prevention are crucial to improve patient survival.
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Affiliation(s)
- Akihiko Okamura
- Department of Gastroenterological Surgery, Gastroenterology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Masaru Hayami
- Department of Gastroenterological Surgery, Gastroenterology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Ryotaro Kozuki
- Department of Gastroenterological Surgery, Gastroenterology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Keita Takahashi
- Department of Gastroenterological Surgery, Gastroenterology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Tasuku Toihata
- Department of Gastroenterological Surgery, Gastroenterology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yu Imamura
- Department of Gastroenterological Surgery, Gastroenterology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Shinji Mine
- Department of Esophageal and Gastroenterological Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Gastroenterology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
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9
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Prognostic Factors of Salvage Esophagectomy for Residual or Recurrent Esophageal Squamous Cell Carcinoma After Definitive Chemoradiotherapy. World J Surg 2018; 42:2887-2893. [PMID: 29423738 DOI: 10.1007/s00268-018-4536-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The aim of this study was to confirm prognostic factors for salvage esophagectomy for remnant or recurrent esophageal squamous cell carcinoma after definitive chemoradiotherapy. STUDY DESIGN We retrospectively analyzed clinicopathological backgrounds of 50 patients who underwent salvage esophagectomy between April 2005 and January 2016. Salvage esophagectomy comprised 40 three-incision esophagectomies, two transhiatal esophagectomies and eight pharyngolaryngoesophagectomies. Independent prognostic factors for overall survival were assessed using Cox regression analysis of the factors. RESULTS Salvage esophagectomy remains a highly invasive surgery and correlated with a higher incidence of all morbidities of Clavien-Dindo classification (CDc) ≥II, severe morbidities of CDc ≥ IIIb, any pulmonary morbidities and chylorrhea, compared with those in patients without preoperative definitive chemoradiotherapy. Cox regression analysis suggested that R0 resection (hazard ratio [HR] 6.39; 95% confidence interval [CI] 2.03-9.68, P = 0.002), absence of severe complications (HR 4.97; 95% CI 1.70-14.81, P = 0.004) and early pStage (0-II) (HR 3.42; 95% CI 1.24-10.12, P = 0.018) were independent prognostic factors for salvage esophagectomy. CONCLUSIONS Salvage esophagectomy remains correlated with a high incidence of postoperative complications. Avoiding non-curative surgery and reducing the incidence of severe postoperative complications are important if patients are to receive prognostic benefit of this highly invasive surgery.
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Faiz Z, Dijksterhuis WPM, Burgerhof JGM, Muijs CT, Mul VEM, Wijnhoven BPL, Smit JK, Plukker JTM. A meta-analysis on salvage surgery as a potentially curative procedure in patients with isolated local recurrent or persistent esophageal cancer after chemoradiotherapy. Eur J Surg Oncol 2018; 45:931-940. [PMID: 30447937 DOI: 10.1016/j.ejso.2018.11.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 10/01/2018] [Accepted: 11/02/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Isolated local recurrent or persistent esophageal cancer (EC) after curative intended definitive (dCRT) or neoadjuvant chemoradiotherapy (nCRT) with initially omitted surgery, is a potential indication for salvage surgery. We aimed to evaluate safety and efficacy of salvage surgery in these patients. MATERIAL AND METHODS A systematic literature search following PRISMA guidelines was performed using databases of PubMed/Medline. All included studies were performed in patients with persistent or recurrent EC after initial treatment with dCRT or nCRT, between 2007 and 2017. Survival analysis was performed with an inverse-variance weighting method. RESULTS Of the 278 identified studies, 28 were eligible, including a total of 1076 patients. Postoperative complications after salvage esophagectomy were significantly more common among patients with isolated persistent than in those with locoregional recurrent EC, including respiratory (36.6% versus 22.7%; difference in proportion 10.9 with 95% confidence interval (CI) [3.1; 18.7]) and cardiovascular complications (10.4% versus 4.5%; difference in proportion 5.9 with 95% CI [1.5; 10.2]). The pooled estimated 30- and 90-day mortality was 2.6% [1.6; 3.6] and 8.0% [6.3; 9.8], respectively. The pooled estimated 3-year and 5-year overall survival (OS) were 39.0% (95% CI: [35.8; 42.2]) and 19.4% [95% CI:16.5; 22.4], respectively. Patients with isolated persistent or recurrent EC after initial CRT had similar 5-year OS (14.0% versus 19.7%, difference in proportion -5.7, 95% CI [-13.7; 2.3]). CONCLUSIONS Salvage surgery is a potentially curative procedure in patients with locally recurrent or persistent esophageal cancer and can be performed safely after definitive or neoadjuvant chemoradiotherapy when surgery was initially omitted.
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Affiliation(s)
- Z Faiz
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - W P M Dijksterhuis
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - J G M Burgerhof
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - C T Muijs
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - V E M Mul
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - B P L Wijnhoven
- Department of Surgery, University of Rotterdam, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - J K Smit
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Surgery, Ziekenhuis Groep Twente, Almelo, the Netherlands
| | - J T M Plukker
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
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11
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Qin Q, Xu H, Liu J, Zhang C, Xu L, Di X, Zhang X, Sun X. Does timing of esophagectomy following neoadjuvant chemoradiation affect outcomes? A meta-analysis. Int J Surg 2018; 59:11-18. [PMID: 30261331 DOI: 10.1016/j.ijsu.2018.09.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 09/05/2018] [Accepted: 09/19/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND The optimal timing of esophagectomy after neoadjuvant chemoradiation treatment (nCRT) remains unclear. Here, a meta-analysis was conducted to determine whether prolonged interval between nCRT and surgery can affect the outcomes in esophageal cancer. MATERIALS AND METHODS The databases PubMed, Embase, Web of Science, and Cochrane were systematically searched for studies reporting the outcomes in esophageal cancer according to the length of interval between nCRT and surgery. The primary outcome was rate of pathologic complete response (pCR), and the secondary outcomes included R0 resection rate, incidence of anastomotic leak, postoperative mortality, and two or five-year overall survival (OS). The intervals were classified into dichotomous (≤7-8 weeks and >7-8 weeks) for the pooled analysis, and a combined relative risk (RR) was calculated. RESULTS A total of 13 studies involving 15,086 patients were analyzed. The overall results indicated that an interval longer than 7-8 weeks between the end of nCRT and the surgery was significantly associated with an improved pCR rate (RR, 1.13; 95% confidence interval [CI], 1.05-1.21; P = 0.001). However, it was related to a higher 30-day surgical mortality (RR, 1.51; 95% CI, 1.19-1.92; P = 0.0006). The subgroup analyses only detected a significant association of the extended interval with pCR and the surgical mortality rate in adenocarcinoma patients. Moreover, an increased time interval resulted in a lower 2-year (RR, 0.94; 95% CI, 0.90-0.98; P = 0.002) and 5-year OS (RR, 0.88; 95% CI, 0.82-0.95; P = 0.0009). No association with R0 resection rate or anastomotic complication resulting from delayed resection was detected. CONCLUSIONS Although increasing the time interval from nCRT to esophagectomy was associated with significantly higher pathologic complete response rates in esophageal cancer, delaying the surgery might be disadvantageous for the long-term survival.
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Affiliation(s)
- Qin Qin
- Department of Radiation Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Huazhong Xu
- Department of Neurosurgery, Sir Run Run Shaw Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Jia Liu
- Department of Radiation Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Chi Zhang
- Department of Radiation Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Liping Xu
- Department of Radiation Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaoke Di
- Department of Radiation Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaowen Zhang
- Department of Radiation Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xinchen Sun
- Department of Radiation Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
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Effeney R, Shaw T, Burmeister BH, Burmeister E, Harvey J, Mai GT, Thomas J, Barbour AP, Smithers BM, Pryor DI. Patterns of Failure Following Dose-escalated Chemoradiotherapy for Fluorodeoxyglucose Positron Emission Tomography Staged Squamous Cell Carcinoma of the Oesophagus. Clin Oncol (R Coll Radiol) 2018; 30:642-649. [PMID: 30017206 DOI: 10.1016/j.clon.2018.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 06/05/2018] [Accepted: 06/10/2018] [Indexed: 12/12/2022]
Abstract
AIMS To analyse outcomes and patterns of failure following dose-escalated definitive chemoradiotherapy (CRT) for oesophageal squamous cell carcinoma using fluorodeoxyglucose positron emission tomography for staging and treatment planning. MATERIALS AND METHODS A retrospective review of patients with oesophageal squamous cell carcinoma receiving definitive CRT to a dose of ≥56 Gy was conducted. Patient and tumour characteristics, treatment received and first sites of relapse were analysed. RESULTS Between 2003 and 2014, 72 patients were treated with CRT to a median dose of 60 Gy (range 56-66 Gy). The median age was 63 years; most (61%) were stage III/IVa. The median follow-up was 57 months. Three year in-field control, relapse-free survival and overall survival was 64% (95% confidence interval 50-75%), 38% (95% confidence interval 27-50%) and 42% (95% confidence interval 30-53%), respectively. Of the 41 failures prior to death or at last follow-up date, isolated locoregional relapse occurred in 16 patients (22%) with isolated in-field recurrence in 11 patients (15%). Distant failure as first site of relapse was present in 25 patients (35%). No in-field failures occurred in the 11 patients with cT1-2, N0-1 tumours. The median survival for cT4 tumours was 8 months, with five of eight patients developing local progression within the first 6 months. CONCLUSIONS Dose-escalated radiotherapy was associated with promising rates of in-field local control, with the exception of cT4 tumours. Distant failure remains a significant competing risk. Our data supports the need for current trials re-examining the role of dose escalation in the modern era.
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Affiliation(s)
- R Effeney
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
| | - T Shaw
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - B H Burmeister
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - E Burmeister
- Nursing Practice Development Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - J Harvey
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - G T Mai
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - J Thomas
- Upper Gastro-intestinal and Soft Tissue Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - A P Barbour
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Upper Gastro-intestinal and Soft Tissue Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia; Surgical Oncology Group, Diamantina Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - B M Smithers
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Upper Gastro-intestinal and Soft Tissue Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - D I Pryor
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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13
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Cohen C, Tessier W, Gronnier C, Renaud F, Pasquer A, Théreaux J, Gagnière J, Meunier B, Collet D, Piessen G, Mariette C. Salvage Surgery for Esophageal Cancer: How to Improve Outcomes? Ann Surg Oncol 2018; 25:1277-1286. [PMID: 29417405 DOI: 10.1245/s10434-018-6365-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Charlotte Cohen
- Department of Digestive and Oncological Surgery, Centre Hospitalier Régional Universitaire, University Hospital Claude Huriez, Lille Cedex, France. .,Department of Thoracic Surgery, Centre Hospitalier Universitaire de Nice, Hopital Pasteur, Nice Cedex 1, France.
| | - Williams Tessier
- Department of Digestive and Oncological Surgery, Centre Hospitalier Régional Universitaire, University Hospital Claude Huriez, Lille Cedex, France.,University Lille Nord de France, Lille Cedex, France
| | - Caroline Gronnier
- Department of Digestive and Oncological Surgery, Centre Hospitalier Régional Universitaire, University Hospital Claude Huriez, Lille Cedex, France.,University Lille Nord de France, Lille Cedex, France.,Inserm, UMR-S 1172, Team 5 "Mucins, epithelial differentiation and carcinogenesis", Lille Cedex, France
| | - Florence Renaud
- Department of Digestive and Oncological Surgery, Centre Hospitalier Régional Universitaire, University Hospital Claude Huriez, Lille Cedex, France.,University Lille Nord de France, Lille Cedex, France.,Inserm, UMR-S 1172, Team 5 "Mucins, epithelial differentiation and carcinogenesis", Lille Cedex, France.,Department of Pathology, Lille University Hospital, Lille Cedex, France
| | - Arnaud Pasquer
- Department of Digestive Surgery, Edouard Herriot University Hospital, Lyon, France
| | - Jérémie Théreaux
- Department of Digestive Surgery, Cavale Blanche University Hospital, Brest, France
| | - Johan Gagnière
- Department of Digestive Surgery, Estaing University Hospital, Clermont-Ferrand, France
| | - Bernard Meunier
- Department of Digestive Surgery, Pontchaillou University Hospital, Rennes, France
| | - Denis Collet
- Department of Digestive Surgery, Haut-Levêque University Hospital, Bordeaux, France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Centre Hospitalier Régional Universitaire, University Hospital Claude Huriez, Lille Cedex, France.,University Lille Nord de France, Lille Cedex, France.,Inserm, UMR-S 1172, Team 5 "Mucins, epithelial differentiation and carcinogenesis", Lille Cedex, France
| | - Christophe Mariette
- Department of Digestive and Oncological Surgery, Centre Hospitalier Régional Universitaire, University Hospital Claude Huriez, Lille Cedex, France.,University Lille Nord de France, Lille Cedex, France.,Inserm, UMR-S 1172, Team 5 "Mucins, epithelial differentiation and carcinogenesis", Lille Cedex, France.,SIRIC ONCOLille, Lille, France
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Park IH, Kim JY. Surveillance or resection after chemoradiation in esophageal cancer. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:82. [PMID: 29666805 DOI: 10.21037/atm.2017.12.16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The treatment of locally advanced esophageal cancer continues to evolve. Previously, surgery was considered the foundation of treatment, but chemoradiation (CRT) has taken on a larger role both in the neoadjuvant setting and as definitive treatment. It has become clear that although some patients benefit from esophagectomy after CRT, a large subset of patients likely derive no benefit, and may be harmed by surgery. Some patients are cured from CRT alone and therefore do not need surgery. Another group of patients likely have metastatic disease at the time of local therapy that is just undetected on imaging and also do not benefit from surgery. A third group of patients will have persistent locoregional disease only after CRT. This last group is the subset who will actually benefit from surgery, but this likely comprises only a minority of patients with locally advanced disease. A strategy to maximize survival while minimizing unnecessary surgery is a reasonable goal, but present technology does not allow us to do this with certainty. Thus, the decision of whether to pursue resection or surveillance after CRT can be difficult as clinicians and patients try to balance the goal of maximizing the likelihood of cure against the risk of surgery and its impact on quality of life.
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Affiliation(s)
- Il-Hwan Park
- Department of Chest Surgery, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Jae Y Kim
- Division of Thoracic Surgery, City of Hope Cancer Center, Duarte, CA, USA
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15
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Abstract
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.
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Affiliation(s)
- Sara Jamel
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Sheraz R Markar
- Department of Surgery and Cancer, Imperial College London, London, UK
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16
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Kumagai K, Mariosa D, Tsai JA, Nilsson M, Ye W, Lundell L, Rouvelas I. Systematic review and meta-analysis on the significance of salvage esophagectomy for persistent or recurrent esophageal squamous cell carcinoma after definitive chemoradiotherapy. Dis Esophagus 2016; 29:734-739. [PMID: 26316181 DOI: 10.1111/dote.12399] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- K Kumagai
- Center for Digestive Diseases, Karolinska University Hospital, Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
| | - D Mariosa
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - J A Tsai
- Center for Digestive Diseases, Karolinska University Hospital, Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - M Nilsson
- Center for Digestive Diseases, Karolinska University Hospital, Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - W Ye
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - L Lundell
- Center for Digestive Diseases, Karolinska University Hospital, Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - I Rouvelas
- Center for Digestive Diseases, Karolinska University Hospital, Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
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Ohashi S, Miyamoto S, Kikuchi O, Goto T, Amanuma Y, Muto M. Recent Advances From Basic and Clinical Studies of Esophageal Squamous Cell Carcinoma. Gastroenterology 2015; 149:1700-15. [PMID: 26376349 DOI: 10.1053/j.gastro.2015.08.054] [Citation(s) in RCA: 383] [Impact Index Per Article: 42.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 08/17/2015] [Accepted: 08/17/2015] [Indexed: 02/08/2023]
Abstract
Esophageal squamous cell carcinoma (ESCC) is one of the most aggressive squamous cell carcinomas and is highly prevalent in Asia. Alcohol and its metabolite, acetaldehyde, are considered definite carcinogens for the esophagus. Polymorphisms in the aldehyde dehydrogenase 2 gene, which encodes an enzyme that eliminates acetaldehyde, have been associated with esophageal carcinogenesis. Studies of the mutagenic and carcinogenic effects of acetaldehyde support this observation. Several recent large-scale comprehensive analyses of the genomic alterations in ESCC have shown a high frequency of mutations in genes such as TP53 and others that regulate the cell cycle or cell differentiation. Moreover, whole genome and whole exome sequencing studies have frequently detected somatic mutations, such as G:C→A:T transitions or G:C→C:G transversions, in ESCC tissues. Genomic instability, caused by abnormalities in the Fanconi anemia DNA repair pathway, is also considered a pathogenic mechanism of ESCC. Advances in diagnostic techniques such as magnifying endoscopy with narrow band imaging or positron emission tomography have increased the accuracy of diagnosis of ESCC. Updated guidelines from the National Comprehensive Cancer Network standardize the practice for the diagnosis and treatment of esophageal cancer. Patients with ESCC are treated endoscopically or with surgery, chemotherapy, or radiotherapy, based on tumor stage. Minimally invasive treatments help improve the quality of life of patients who undergo such treatments. We review recent developments in the diagnosis and treatment of ESCC and advances gained from basic and clinical research.
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Affiliation(s)
- Shinya Ohashi
- Department of Therapeutic Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan; Department of Clinical Oncology, Kyoto University Hospital Cancer Center, Kyoto, Japan
| | - Shin'ichi Miyamoto
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Osamu Kikuchi
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomoyuki Goto
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yusuke Amanuma
- Department of Therapeutic Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan; Department of Clinical Oncology, Kyoto University Hospital Cancer Center, Kyoto, Japan
| | - Manabu Muto
- Department of Therapeutic Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan; Department of Clinical Oncology, Kyoto University Hospital Cancer Center, Kyoto, Japan.
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18
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Markar S, Gronnier C, Duhamel A, Pasquer A, Théreaux J, du Rieu MC, Lefevre JH, Turner K, Luc G, Mariette C. Salvage Surgery After Chemoradiotherapy in the Management of Esophageal Cancer: Is It a Viable Therapeutic Option? J Clin Oncol 2015. [PMID: 26195702 DOI: 10.1200/jco.2014.59.9092] [Citation(s) in RCA: 136] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Sheraz Markar
- Sheraz Markar, Imperial College, London, United Kingdom; Caroline Gronnier, Christophe Mariette, and Alain Duhamel, Site de Recherche Intégrée sur le Cancer OncoLille; North of France University; University Hospital of Lille; Caroline Gronnier and Christophe Mariette, INSERM UMR S-1172, Jean Pierre Aubert Research Center, Lille; Arnaud Pasquer and Christophe Mariette, Edouard Herriot University Hospital, Lyon; Jérémie Théreaux, Cavale Blanche University Hospital, Brest; Mael Chalret du Rieu, Purpan University Hospital, Toulouse; Jérémie H. Lefevre, Saint Antoine University Hospital, Paris; Kathleen Turner, Pontchaillou University Hospital, Rennes; and Guillaume Luc, Haut-Levêque University Hospital, Bordeaux, France
| | - Caroline Gronnier
- Sheraz Markar, Imperial College, London, United Kingdom; Caroline Gronnier, Christophe Mariette, and Alain Duhamel, Site de Recherche Intégrée sur le Cancer OncoLille; North of France University; University Hospital of Lille; Caroline Gronnier and Christophe Mariette, INSERM UMR S-1172, Jean Pierre Aubert Research Center, Lille; Arnaud Pasquer and Christophe Mariette, Edouard Herriot University Hospital, Lyon; Jérémie Théreaux, Cavale Blanche University Hospital, Brest; Mael Chalret du Rieu, Purpan University Hospital, Toulouse; Jérémie H. Lefevre, Saint Antoine University Hospital, Paris; Kathleen Turner, Pontchaillou University Hospital, Rennes; and Guillaume Luc, Haut-Levêque University Hospital, Bordeaux, France
| | - Alain Duhamel
- Sheraz Markar, Imperial College, London, United Kingdom; Caroline Gronnier, Christophe Mariette, and Alain Duhamel, Site de Recherche Intégrée sur le Cancer OncoLille; North of France University; University Hospital of Lille; Caroline Gronnier and Christophe Mariette, INSERM UMR S-1172, Jean Pierre Aubert Research Center, Lille; Arnaud Pasquer and Christophe Mariette, Edouard Herriot University Hospital, Lyon; Jérémie Théreaux, Cavale Blanche University Hospital, Brest; Mael Chalret du Rieu, Purpan University Hospital, Toulouse; Jérémie H. Lefevre, Saint Antoine University Hospital, Paris; Kathleen Turner, Pontchaillou University Hospital, Rennes; and Guillaume Luc, Haut-Levêque University Hospital, Bordeaux, France
| | - Arnaud Pasquer
- Sheraz Markar, Imperial College, London, United Kingdom; Caroline Gronnier, Christophe Mariette, and Alain Duhamel, Site de Recherche Intégrée sur le Cancer OncoLille; North of France University; University Hospital of Lille; Caroline Gronnier and Christophe Mariette, INSERM UMR S-1172, Jean Pierre Aubert Research Center, Lille; Arnaud Pasquer and Christophe Mariette, Edouard Herriot University Hospital, Lyon; Jérémie Théreaux, Cavale Blanche University Hospital, Brest; Mael Chalret du Rieu, Purpan University Hospital, Toulouse; Jérémie H. Lefevre, Saint Antoine University Hospital, Paris; Kathleen Turner, Pontchaillou University Hospital, Rennes; and Guillaume Luc, Haut-Levêque University Hospital, Bordeaux, France
| | - Jérémie Théreaux
- Sheraz Markar, Imperial College, London, United Kingdom; Caroline Gronnier, Christophe Mariette, and Alain Duhamel, Site de Recherche Intégrée sur le Cancer OncoLille; North of France University; University Hospital of Lille; Caroline Gronnier and Christophe Mariette, INSERM UMR S-1172, Jean Pierre Aubert Research Center, Lille; Arnaud Pasquer and Christophe Mariette, Edouard Herriot University Hospital, Lyon; Jérémie Théreaux, Cavale Blanche University Hospital, Brest; Mael Chalret du Rieu, Purpan University Hospital, Toulouse; Jérémie H. Lefevre, Saint Antoine University Hospital, Paris; Kathleen Turner, Pontchaillou University Hospital, Rennes; and Guillaume Luc, Haut-Levêque University Hospital, Bordeaux, France
| | - Mael Chalret du Rieu
- Sheraz Markar, Imperial College, London, United Kingdom; Caroline Gronnier, Christophe Mariette, and Alain Duhamel, Site de Recherche Intégrée sur le Cancer OncoLille; North of France University; University Hospital of Lille; Caroline Gronnier and Christophe Mariette, INSERM UMR S-1172, Jean Pierre Aubert Research Center, Lille; Arnaud Pasquer and Christophe Mariette, Edouard Herriot University Hospital, Lyon; Jérémie Théreaux, Cavale Blanche University Hospital, Brest; Mael Chalret du Rieu, Purpan University Hospital, Toulouse; Jérémie H. Lefevre, Saint Antoine University Hospital, Paris; Kathleen Turner, Pontchaillou University Hospital, Rennes; and Guillaume Luc, Haut-Levêque University Hospital, Bordeaux, France
| | - Jérémie H Lefevre
- Sheraz Markar, Imperial College, London, United Kingdom; Caroline Gronnier, Christophe Mariette, and Alain Duhamel, Site de Recherche Intégrée sur le Cancer OncoLille; North of France University; University Hospital of Lille; Caroline Gronnier and Christophe Mariette, INSERM UMR S-1172, Jean Pierre Aubert Research Center, Lille; Arnaud Pasquer and Christophe Mariette, Edouard Herriot University Hospital, Lyon; Jérémie Théreaux, Cavale Blanche University Hospital, Brest; Mael Chalret du Rieu, Purpan University Hospital, Toulouse; Jérémie H. Lefevre, Saint Antoine University Hospital, Paris; Kathleen Turner, Pontchaillou University Hospital, Rennes; and Guillaume Luc, Haut-Levêque University Hospital, Bordeaux, France
| | - Kathleen Turner
- Sheraz Markar, Imperial College, London, United Kingdom; Caroline Gronnier, Christophe Mariette, and Alain Duhamel, Site de Recherche Intégrée sur le Cancer OncoLille; North of France University; University Hospital of Lille; Caroline Gronnier and Christophe Mariette, INSERM UMR S-1172, Jean Pierre Aubert Research Center, Lille; Arnaud Pasquer and Christophe Mariette, Edouard Herriot University Hospital, Lyon; Jérémie Théreaux, Cavale Blanche University Hospital, Brest; Mael Chalret du Rieu, Purpan University Hospital, Toulouse; Jérémie H. Lefevre, Saint Antoine University Hospital, Paris; Kathleen Turner, Pontchaillou University Hospital, Rennes; and Guillaume Luc, Haut-Levêque University Hospital, Bordeaux, France
| | - Guillaume Luc
- Sheraz Markar, Imperial College, London, United Kingdom; Caroline Gronnier, Christophe Mariette, and Alain Duhamel, Site de Recherche Intégrée sur le Cancer OncoLille; North of France University; University Hospital of Lille; Caroline Gronnier and Christophe Mariette, INSERM UMR S-1172, Jean Pierre Aubert Research Center, Lille; Arnaud Pasquer and Christophe Mariette, Edouard Herriot University Hospital, Lyon; Jérémie Théreaux, Cavale Blanche University Hospital, Brest; Mael Chalret du Rieu, Purpan University Hospital, Toulouse; Jérémie H. Lefevre, Saint Antoine University Hospital, Paris; Kathleen Turner, Pontchaillou University Hospital, Rennes; and Guillaume Luc, Haut-Levêque University Hospital, Bordeaux, France
| | - Christophe Mariette
- Sheraz Markar, Imperial College, London, United Kingdom; Caroline Gronnier, Christophe Mariette, and Alain Duhamel, Site de Recherche Intégrée sur le Cancer OncoLille; North of France University; University Hospital of Lille; Caroline Gronnier and Christophe Mariette, INSERM UMR S-1172, Jean Pierre Aubert Research Center, Lille; Arnaud Pasquer and Christophe Mariette, Edouard Herriot University Hospital, Lyon; Jérémie Théreaux, Cavale Blanche University Hospital, Brest; Mael Chalret du Rieu, Purpan University Hospital, Toulouse; Jérémie H. Lefevre, Saint Antoine University Hospital, Paris; Kathleen Turner, Pontchaillou University Hospital, Rennes; and Guillaume Luc, Haut-Levêque University Hospital, Bordeaux, France.
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19
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Watanabe M, Mine S, Nishida K, Yamada K, Shigaki H, Matsumoto A, Sano T. Salvage Esophagectomy After Definitive Chemoradiotherapy for Patients with Esophageal Squamous Cell Carcinoma: Who Really Benefits from this High-Risk Surgery? Ann Surg Oncol 2015; 22:4438-44. [PMID: 25862582 DOI: 10.1245/s10434-015-4556-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Masayuki Watanabe
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Shinji Mine
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Koujiro Nishida
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kazuhiko Yamada
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hironobu Shigaki
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akira Matsumoto
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takeshi Sano
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
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20
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Schweigert M, Solymosi N, Dubecz A, Posada Gonzalez M, Stadlhuber RJ, Ofner D, Stein HJ. Emergency oesophagectomy for oesophageal perforation after chemoradiotherapy for oesophageal cancer. Ann R Coll Surg Engl 2015; 97:140-5. [PMID: 25723692 PMCID: PMC4473392 DOI: 10.1308/003588414x14055925060631] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2014] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Oesophageal perforation following chemoradiotherapy for oesophageal cancer is a devastating condition but there have been no studies investigating the role of emergency oesophagectomy for this life threatening situation. METHODS This retrospective study comprised all cases of emergency oesophagectomy for oesophageal perforation after chemoradiotherapy for oesophageal carcinoma at a major centre for oesophageal surgery in Germany between 2004 and 2013. RESULTS A total of 13 patients (mean age: 58.9 years) were identified. During the same time period, 356 elective oesophagectomies were performed. Tumour entities were squamous cell carcinoma (n=12) and adenocarcinoma of the oesophagus (n=1). Alcoholism (odds ratio [OR]: 25.79, 95% confidence interval [CI]: 6.70-121.70, p<0.0001) and chronic pulmonary disease (OR: 3.76, 95% CI: 1.06-14.96, p=0.027) were more common among the emergency cases. Oesophageal rupture was caused by perforation of an oesophageal stent (10 cases) or perforation during implantation of a percutaneous endoscopic gastrostomy tube (3 cases). Emergency oesophagectomy was carried out either as discontinuity resection (10/13) or oesophagectomy with immediate reconstruction (3/13). Compared with the elective cases, patients undergoing emergency oesophagectomy had significantly higher odds for sustaining perioperative sepsis (OR: 4.42, 95% CI: 1.23-16.45, p=0.01), acute renal failure (OR: 6.49, 95% CI: 1.57-24.15, p=0.005) and pneumonia (OR: 24.33, 95% CI: 3.52-1,046.65, p<0.0001). Furthermore, slow respiratory weaning was more common and there was a significantly higher tracheostomy rate (OR: 4.64, 95% CI: 1.14-16.98, p=0.02). Oesophageal discontinuity was eventually reversed in eight patients. Emergency oesophagectomy patients had odds that were three times higher for fatal outcome (OR: 3.59, 95% CI: 0.77-13.64, p=0.05). The overall mortality was 4/13. The remaining nine patients had a mean survival of 25.1 months (range: 5-46 months). The two-year-survival-rate was 38.5% (5/13). CONCLUSIONS Despite the most unfavourable preconditions, the results of emergency oesophagectomy for oesophageal perforation after chemoradiotherapy are not desperate. The procedure is not only justified but life saving.
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Affiliation(s)
- M Schweigert
- Klinikum Nürnberg, Germany
- Paracelsus Medical University, Salzburg, Austria
| | - N Solymosi
- Szent István University, Budapest, Hungary
| | - A Dubecz
- Klinikum Nürnberg, Germany
- Paracelsus Medical University, Salzburg, Austria
| | | | - RJ Stadlhuber
- Klinikum Nürnberg, Germany
- Paracelsus Medical University, Salzburg, Austria
| | - D Ofner
- Paracelsus Medical University, Salzburg, Austria
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21
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Schmidt T, Sisic L, Sterzing F, Haag GM, Kunzmann R, Grenacher L, Weichert W, Jäger D, Büchler MW, Ott K. [Salvage surgery in esophageal cancer : Feasibility in patients after definitive radiochemotherapy (> 50 Gy)]. Chirurg 2015; 86:955-62. [PMID: 25715974 DOI: 10.1007/s00104-014-2971-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- T Schmidt
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Deutschland
| | - L Sisic
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Deutschland
| | - F Sterzing
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Deutschland
| | - G-M Haag
- Department of Medical Oncology, National Center of Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Deutschland
| | - R Kunzmann
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Deutschland
| | - L Grenacher
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Deutschland
| | - W Weichert
- Department of Pathology, University of Heidelberg, Heidelberg, Deutschland
| | - D Jäger
- Department of Medical Oncology, National Center of Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Deutschland
| | - M W Büchler
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Deutschland
| | - K Ott
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Deutschland.
- Department of General, Vascular and Thoracic Surgery, Klinik für Allgemein-, Gefäß- und Thoraxchirurgie, RoMed Klinikum Rosenheim, Pettenkoferstr. 10, 83022, Rosenheim, Deutschland.
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22
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Chiu CH, Chao YK, Chang HK, Tseng CK, Chan SC, Liu YH, Chen WH. Interval between neoadjuvant chemoradiotherapy and surgery for esophageal squamous cell carcinoma: does delayed surgery impact outcome? Ann Surg Oncol 2014; 20:4245-51. [PMID: 23959050 DOI: 10.1245/s10434-013-3139-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Indexed: 01/09/2023]
Abstract
BACKGROUND Although esophagectomy traditionally is recommended to perform within 8 weeks after neoadjuvant chemoradiotherapy (nCRT), data from neoadjuvantly treated rectal cancer patients demonstrate that delayed surgery ([8 weeks) can maximize the effect of CRT. Despite these promising data, investigators are concerned that delayed surgery may lead to tumor repopulation. We report the impact of delayed surgery in patients with esophageal cancer who were treated with nCRT. METHODS We retrospectively studied 276 esophageal cancer patients treated with nCRT and surgery between 2002 and 2008. We compared perioperative complication, rate of pathological complete response (pCR), distribution of tumor regression grade (TRG), and overall survival (OS) in patients who underwent surgery within 8 weeks (group A) and after 8 weeks (group B) after nCRT. RESULTS There were 138 patients in each group with similar pre/post-nCRT characteristics. Delayed surgery did not result in lower surgical risk or higher pCR rate. Survival outcome also did not improve following a longer surgery interval (5-year OS: group A vs. group B, 29 vs. 23 %; P = 0.3). On the contrary, a subgroup analysis showed that delayed surgery might be hazardous, especially in patients who demonstrate a good response after nCRT. The amount of residual cancer, as measured by TRG, increased significantly after a longer surgical interval (P = 0.024). Survival also decreased after a longer surgical interval (5-year OS B8 vs. [8 weeks, 50 vs. 35 %; P = 0.038). CONCLUSIONS After nCRT, esophagectomy should be performed within 8 weeks, especially in patients with good response.
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23
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D'Journo XB, Thomas PA. Current management of esophageal cancer. J Thorac Dis 2014; 6 Suppl 2:S253-64. [PMID: 24868443 DOI: 10.3978/j.issn.2072-1439.2014.04.16] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 04/15/2014] [Indexed: 12/15/2022]
Abstract
Management of esophageal cancer has evolved since the two last decades. Esophagectomy remains the primary treatment for early stage esophageal cancer although its specific role in superficial cancers is still under debate since the development of endoscopic mucosal treatment. To date, there is strong evidence to consider that locally advanced cancers should be recommended for a multimodal treatment with a neoadjuvant chemotherapy or a combined chemoradiotherapy (CRT) followed by surgery. For locally advanced squamous cell carcinoma or for a part of adenocarcinoma, some centers have proposed treating with definitive CRT to avoid related-mortality of surgery. In case of persistent or recurrent disease, a salvage esophagectomy remains a possible option but this procedure is associated with higher levels of perioperative morbidity and mortality. Despite the debate over what constitutes the best surgical approach (transthoracic versus transhiatal), the current question is if a minimally procedure could reduce the periopertive morbidity and mortality without jeopardizing the oncological results of surgery. Since the last decade, minimally invasive esophagectomy (MIE) or hybrid operations are being done in up to 30% of procedures internationally. There are some consistent data that MIE could decrease the incidence of the respiratory complications and decrease the length of hospital-stay. Nowadays, oncologic outcomes appear equivalent between open and minimally invasive procedures but numerous phase III trials are ongoing.
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Affiliation(s)
- Xavier Benoit D'Journo
- Department of Thoracic Surgery and Diseases of the Esophagus, Aix-Marseille University Marseille, France
| | - Pascal Alexandre Thomas
- Department of Thoracic Surgery and Diseases of the Esophagus, Aix-Marseille University Marseille, France
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24
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Wang S, Tachimori Y, Hokamura N, Igaki H, Nakazato H, Kishino T. Prognostic analysis of salvage esophagectomy after definitive chemoradiotherapy for esophageal squamous cell carcinoma: the importance of lymphadenectomy. J Thorac Cardiovasc Surg 2014; 147:1805-11. [PMID: 24521950 DOI: 10.1016/j.jtcvs.2013.12.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 12/19/2013] [Accepted: 12/27/2013] [Indexed: 01/15/2023]
Abstract
OBJECTIVES The objective of this study was to review the prognostic factors for increased survival after salvage esophagectomy after definitive chemoradiotherapy for esophageal squamous carcinoma and determine the importance of lymphadenectomy from a prognostic view. METHODS Clinical data for all patients from January 1999 to December 2012 who underwent salvage esophagectomy for residual tumor or tumor recurrence after definitive chemoradiotherapy were retrospectively collected. Survival was determined and prognostic factors were analyzed with univariate and multivariate analyses. RESULTS Survival after 1, 3, and 5 years postoperatively was 74.4%, 39.8%, and 29.5%, respectively. The independent predictive factors for increased postoperative survival were tumor recurrence rather than residual tumor as the indication for salvage surgery (P < .001; odds ratio [OR], 0.292); complete tumor resection (P < .001; OR, 4.520); N category (P = .089; OR, 1.304); M category (P = .081; OR, 2.215), and total mediastinal dissection with 15 or more dissected mediastinal lymph nodes (P = .034; OR, 0.546). CONCLUSIONS Salvage indications of recurrence, earlier disease, and complete tumor resection are related to longer survival. The total area of mediastinal dissection with a sufficient number of dissected mediastinal lymph nodes improves survival. Additional neck dissection does not add benefit. The optimal procedure for lymph node dissection in salvage esophagectomy should be established in future studies.
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Affiliation(s)
- Shaohua Wang
- Division of Esophageal Surgery, Department of Surgery, National Cancer Center Hospital, Tokyo, Japan; Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yuji Tachimori
- Division of Esophageal Surgery, Department of Surgery, National Cancer Center Hospital, Tokyo, Japan.
| | - Nobukazu Hokamura
- Division of Esophageal Surgery, Department of Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroyasu Igaki
- Division of Esophageal Surgery, Department of Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Hidetsugu Nakazato
- Division of Esophageal Surgery, Department of Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Takayoshi Kishino
- Division of Esophageal Surgery, Department of Surgery, National Cancer Center Hospital, Tokyo, Japan
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25
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Markar SR, Karthikesalingam A, Penna M, Low DE. Assessment of short-term clinical outcomes following salvage esophagectomy for the treatment of esophageal malignancy: systematic review and pooled analysis. Ann Surg Oncol 2013; 21:922-31. [PMID: 24212722 DOI: 10.1245/s10434-013-3364-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Combined chemoradiotherapy is increasingly being used as definitive treatment for locoregional esophageal malignancy. Patients with residual or recurrent localized cancer are often selectively considered for salvage esophagectomy (SALV). The aim of this pooled analysis was to compare short-term clinical outcomes from SALV following definitive chemoradiotherapy with those from planned esophagectomy following neoadjuvant chemoradiotherapy (NCRS). METHODS MEDLINE, EMBASE, Cochrane, trial registries, conference proceedings and reference lists were searched for relevant comparative studies. Primary outcome measures were in-hospital mortality, anastomotic leak and pulmonary complications. Secondary outcomes were length of hospital stay, negative (R0) resection margin, and estimated blood loss. RESULTS Eight studies comprising 954 patients; 242 (SALV) and 712 (NCRS) were included. SALV was associated with a significantly increased incidence of post-operative mortality (9.50 vs. 4.07 %; pooled odds ratio [POR] = 3.02; p < 0.001), anastomotic leak (23.97 vs. 14.47 %; POR = 1.99; p = 0.005), pulmonary complications (29.75 vs. 16.99 %; POR = 2.12; p < 0.001), and an increased length of hospital stay (weighted mean difference = 8.29 days; 95 % CI 7.08-9.5; p < 0.001). There were no significant differences between the groups in the incidence of negative resection margins or estimated blood loss. CONCLUSIONS SALV has poorer short-term outcomes when compared with planned esophagectomy following neoadjuvant chemoradiotherapy. Patients and multidisciplinary tumor boards should be made aware of these differences in outcomes and SALV should be reserved for practice in high-volume institutions.
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Affiliation(s)
- Sheraz R Markar
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA, USA
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26
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Bronson NW, Luna RA, Hunter JG. Tailoring esophageal cancer surgery. Semin Thorac Cardiovasc Surg 2013; 24:275-87. [PMID: 23465676 DOI: 10.1053/j.semtcvs.2012.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2012] [Indexed: 12/15/2022]
Abstract
Esophageal cancer is a significant source of major mortality worldwide and is increasing dramatically in incidence. Without treatment this disease leads rapidly to death, but intervention also carries significant risk, so a carefully tailored approach must be used to maximize oncological efficacy while minimizing the negative consequences of intervention. Careful patient selection based on histologic and anatomic staging, consideration of each patient's clinical variables, appropriately timing chemo- and radiation therapy, and minimizing the morbidity of surgical intervention may significantly improve a patient's chances of surviving this disease, but each must be carefully orchestrated with a tailored approach to treatment. This review will serve as a guide to tailoring surgery for esophageal cancer.
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Affiliation(s)
- Nathan W Bronson
- Department of Surgery, Oregon Health & Science University, Portland, Oregon 97239, USA
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27
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Abstract
Esophageal resection remains the primary treatment for local regional esophageal cancer, although its role in superficial (T1A) cancers and squamous cell cancer is in evolution. Mortality associated with esophagectomy has historically been high but is improving with the current expectation of in-hospital mortality rates of 2-4% in high-volume centers. Most patients with regional cancers (T2-4 N0-3) are recommended for neoadjuvant therapy, which most commonly involves radiochemotherapy. Some centers have proposed treating with definitive chemoradiation and reserving surgery for patients who have persistent or recurrent disease. 'Salvage resections' are possible but are associated with higher levels of perioperative morbidity and mortality, and treatment decisions should routinely be based on multidisciplinary discussion in the tumor board. Although open surgical resection (both transthoracic and transhiatal operations) remain the most common approach, minimally invasive or hybrid operations are being done in up to 30% of procedures internationally. There are some indications that minimally invasive esophagectomy may decrease the incidence of respiratory complications and decrease length of stay. At this point, oncologic outcomes appear equivalent between open and minimally invasive procedures. Recent reviews from high-volume esophagectomy centers demonstrate that elderly patients can selectively undergo esophagectomy with the expectation of increased complications but similar mortality and survival to younger patients. Multiple studies confirm that quality of life following esophagectomy can be equivalent to the general population when surgery is done in experienced centers. Patients requiring surgical treatment of esophageal cancer should be referred to high-volume centers, especially those with established care pathways or enhanced recovery programs to improve outcomes including morbidity, mortality, survival, and quality of life.
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Affiliation(s)
- Donald E Low
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, WA 98111, USA.
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28
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Rice TW. Esophageal Nightmare: Cancer Recurrence After Definitive Chemoradiation. Is Salvage Esophagectomy Possible? Semin Thorac Cardiovasc Surg 2013; 25:83-6. [DOI: 10.1053/j.semtcvs.2013.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2013] [Indexed: 11/11/2022]
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29
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Lymphadenectomy via a cervical approach for upper mediastinal lymph node recurrence of esophageal cancer: Report of a case. Surg Today 2011; 41:1562-6. [DOI: 10.1007/s00595-010-4521-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Accepted: 11/08/2010] [Indexed: 10/17/2022]
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30
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Implementation of single incision laparoscopic appendectomy (SIL-A) as standard procedure for appendectomy in a rural hospital setting. Eur Surg 2011. [DOI: 10.1007/s10353-010-0584-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Hoffmann AC, Vallböhmer D, Grimminger P, Metzger R, Prenzel KL, Hoelscher AH, Brabender J. Preoperative survivin mRNA detection in peripheral blood is an independent predictor of outcome in esophageal carcinoma. Pharmacogenomics 2010; 11:341-7. [PMID: 20235790 DOI: 10.2217/pgs.09.164] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
AIMS Survivin (SVV) mRNA expression levels in peripheral blood of patients with gastrointestinal malignancies change significantly during the course of treatment. We wanted to scrutinize these findings in patients with esophageal carcinoma and furthermore evaluate whether the detection of mRNA and the change in detecting ability have an association with overall survival. MATERIALS & METHODS Whole blood was drawn 1 day pre- and 10 days post-operatively from 62 patients with esophageal carcinoma. Tumor cells were enriched from whole blood by density-gradient centrifugation prior to extraction of total cellular RNA and subsequent direct quantitative reverse transcriptase-PCR assays. RESULTS SVV was detectable in 48 out of 62 patients (77%). Stepwise multivariate Cox linear regression models demonstrated a significant and independent association of measured SVV with overall survival (6.6 exp[b]; 95% CI: 1.97-22.12; p = 0.002). Increased SVV levels after the operation were linked to shorter overall survival (p = 0.04). CONCLUSION Preoperative SVV expression levels appear to be associated with overall survival in patients with esophageal cancers. Increasing levels could potentially indicate a higher risk for shorter overall survival and therefore demand adapted treatment modalities.
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Affiliation(s)
- Andreas-Claudius Hoffmann
- Department of Medicine (Cancer Research), Molecular Oncology Risk-Profile Evaluation, West German Cancer Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany.
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Miyata H, Yamasaki M, Takiguchi S, Nakajima K, Fujiwara Y, Nishida T, Mori M, Doki Y. Salvage esophagectomy after definitive chemoradiotherapy for thoracic esophageal cancer. J Surg Oncol 2009; 100:442-6. [PMID: 19653262 DOI: 10.1002/jso.21353] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES Although locoregional failure frequently occurs after definitive chemoradiotherapy (CRT), the role of salvage esophagectomy has not been fully evaluated. The aim of this study was to compare the outcome of salvage esophagectomy after high-dose definitive CRT with neoadjuvant CRT. METHODS From 1994 to 2007, 33 patients with thoracic esophageal cancer underwent salvage esophagectomy after definitive CRT, and 115 patients underwent neoadjuvant CRT followed by surgery. RESULTS The postoperative mortality rate in the salvage group (12%) was higher than in the neoadjuvant group (3.6%, P = 0.059). The rates of postoperative complications were significantly higher in the salvage group than in neoadjuvant group: Anastomotic leakage (39% vs. 22%, respectively, P = 0.049), bleeding (15% vs. 1.7%, respectively, P = 0.002), cardiovascular complications (24% vs. 5.4%, respectively, P = 0.001). Univariate analysis showed that pretherapy T stage, pretherapy lymph node status, pathological T stage, and operative curability were significant prognostic factors affecting survival of patients who underwent salvage esophagectomy. In particular, patients with cT3-T4 tumors or cN1 tumors before definitive CRT showed worse prognosis after salvage esophagectomy. CONCLUSIONS Salvage esophagectomy after high-dose definitive CRT was associated with higher postoperative mortality and morbidity rates compared with neoadjuvant CRT. Only selected patients can be rescued by salvage esophagectomy.
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Affiliation(s)
- Hiroshi Miyata
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan.
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Tachimori Y. Role of salvage esophagectomy after definitive chemoradiotherapy. Gen Thorac Cardiovasc Surg 2009; 57:71-8. [PMID: 19214447 DOI: 10.1007/s11748-008-0337-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Indexed: 01/13/2023]
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.
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Affiliation(s)
- Yuji Tachimori
- Esophageal Surgery Division, Department of Surgery, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo 104-0045, Japan.
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Chowdhury F, Bradley K, Gleeson F. The role of 18F-FDG PET/CT in the evaluation of oesophageal carcinoma. Clin Radiol 2008; 63:1297-309. [DOI: 10.1016/j.crad.2008.05.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2008] [Revised: 05/27/2008] [Accepted: 05/29/2008] [Indexed: 12/19/2022]
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