Salvage lymphadenectomy for recurrent esophageal cancer after chemoradiotherapy

Clinical outcomes of salvage radiotherapy in patients with supraclavicular lymph node metastases after esophagectomy

Purpose

To evaluate the clinical outcomes of salvage radiotherapy in patients with supraclavicular lymph node (SCLN) metastases after esophagectomy.

Methods

After initial esophagectomy (R0 resection), clinical outcomes in patients with esophageal squamous cell carcinoma with SCLN metastases during follow-up were retrospectively analyzed.

Results

A total of 114 patients were split into two groups: the salvage radiotherapy (SR) (n=89) and the control (NSR) (without salvage radiotherapy, n=25). The overall survival rates of 1 year, 3 years and 5 years were 81.6%, 31.4% and 8.6%, accordingly. The 1-year and 3-year survival after SCLN metastases (SASM) rates were 40.2% and 14.5%, respectively; the median SASM time was 10 months. In the SR group, the SASM rates of 1-year and 3-year were 48.1% and 18.9%, compared to 12.0% and 0% in the NSR group (p<0.001). Patients in the SR group who received combined radiochemotherapy experienced 1-year and 3-year SASM rates of 62.6% and 33.4%, compared to 41.9% and 16.5% with single radiotherapy (p<0.001). The salvage radiation dose revealed that the 1-year and 3-year SASM rates turned out to be 56.5% and 23.4% in group of ≥60 Gy, and 29.2% and 7.5% in group of <60 Gy (p<0.001). According to multivariate analysis, combined visceral metastases (CVM), combined mediastinal failure (CMF), salvage radiotherapy, salvage radiation dose and salvage treatment method possibly were identified as important prognostic variables. After propensity score matching (PSM), the above results were similar to those before PSM, except for that only salvage radiotherapy is possibly independent prognostic variables for survival after SCLN metastases in multivariate analysis.

Conclusion

It is possible that salvage radiotherapy can increase the survival rate of patients who receive SCLN metastases following esophagectomy.

Minimally Invasive Salvage Operations for Esophageal Cancer after Definitive Chemoradiotherapy

BACKGROUND/AIMS

Because salvage surgery after definitive chemoradiotherapy for esophageal cancer is associated with high postoperative mortality and morbidity, minimally invasive methods are desirable. We analyzed the validity of minimally invasive salvage operations (MISO).

METHODS

Twenty-five patients underwent salvage operation between 2010 and 2016 in our institution, 10 having undergone right transthoracic salvage esophagectomy (TTSE group), 6 transhiatal salvage esophagectomy (THSE), 6 salvage lymphadenectomy (SLA), and 3 salvage endoscopic submucosal dissection (SESD). Patients who had undergone THSE, SLA, or SESD were categorized as the MISO group. Short- and long-term outcomes were assessed.

RESULTS

The mean duration of surgery was significantly shorter in the SLA groups than in the TTSE group (p = 0.0248). Blood loss was significantly less in the SLA than the TTSE group (p = 0.0340). Intensive care unit stay was shorter in the THSE than the TTSE group (p = 0.0412). There was no significant difference in postoperative mortality between the MISO and THSE groups. Postoperative hospital stay was significantly shorter in the SLA than the TTSE group (p = 0.0061). Patients' survivals did not differ significantly between the MISO and TTSE groups (p = 0.752). Multivariate analysis revealed that residual disease (R0; HR 4.872, 95% CI 1.387-17.110, p = 0.013) was the only independent factor influencing overall survival.

CONCLUSION

MISO is preferable because short-term outcomes are better and long-term outcomes do not differ from those of TTSE.

Interaction between Medical Treatment and Minimally Invasive Surgical Treatment for the Malignancies of the Digestive Tract

Recently, endoscopic diagnosis and treatment methods for early cancer in the digestive tract have made rapid progress. As for surgery, laparoscopic and thoracoscopic techniques have achieved rapidly advancing development in the last 2 decades. Early detection of the malignant lesion and the evolution of endoscopic and surgical device enabled in performing the minimally invasive surgery. Collaboration of medical treatment and minimally invasive surgery for advanced cancer is ongoing in the case of some conditions and in a few institutes. In this review, the contents of the core symposia on "Interaction between medical treatment and minimally invasive surgical treatment for the malignancies of the digestive tract", held at the 11, 12 and 13th annual meeting of the Japanese Gastroenterological Association, are summarized. At each annual meeting, the core symposium focused primarily on gastric, colorectal, and esophageal cancer treatment. For gastric cancer, endoscopic resection and laparoscopic surgery were 2 important key words. For colorectal cancer, multidisciplinary therapy was a major key word. And for esophageal cancer, endoscopic resection, chemoradiotherapy, thoracoscopic surgery and salvage surgery were key words. Patients' survival and quality of life are expected to further advance as a result of the collaboration of such therapeutic modalities.

Long-term outcome after resection for recurrent oesophageal cancer

Background

The efficacy of surgical resection for lymph node (LN) or distant recurrence of oesophageal cancer has not been sufficiently investigated. The objective of this study was to reveal appropriate indications for a surgical approach.

Methods

A total of 42 patients who underwent resection for recurrent or residual oesophageal squamous cell carcinoma after surgery or definitive chemoradiotherapy (dCRT) between April 2004 and August 2016 were identified. These resections did not include salvage oesophagectomy. The long-term outcomes of these patients were retrospectively analysed.

Results

Thirty-three patients underwent LN resection, 6 patients underwent lung resection, and 3 patients underwent resection for other recurrent tumours. The 5-year overall survival (OS) of patients who underwent salvage abdominal lymphadenectomy after dCRT was significantly better than that of patients who underwent salvage cervical or mediastinal lymphadenectomy (46.9% vs. 0.0%, P=0.006). The 5-year OS of patients who underwent salvage resection for LNs outside the radiation field was significantly better than that of patients who underwent resection inside the radiation field (47.6% vs. 8.9%, P=0.027). The 5-year OS of patients who underwent salvage resection for recurrent LNs was significantly better than that of patients who underwent salvage resection for residual LNs (21.7% vs. 0.0%, P<0.001). Among the 42 patients, 9 survived more than 3 years: 4 after salvage abdominal lymphadenectomy, 3 after resection for solitary lung recurrence, and 2 others.

Conclusions

The use of the appropriate surgical approach might improve the prognosis of patients with abdominal LN recurrence, LN recurrence outside the radiation field, or a solitary lung recurrence of oesophageal cancer.

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

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

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

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

Introduction

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

Presentation of case

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

Discussion

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

Conclusions

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

Clinical analyses on salvage lymphadenectomy through cervical incision for patients with cervical and cervicothoracic recurrences after esophagectomy

Background

Locoregional recurrences are often observed after esophagectomy with lymphadenectomy. The treatment strategy for these patients has not been established completely. The purpose of this study was to evaluate the prognosis of salvage lymphadenectomy through the cervical incision for cervical and cervicothoracic recurrences.

Methods

We retrospectively reviewed patients underwent initial esophagectomy and then salvage lymphadenectomy in Fudan University Shanghai Cancer Center during July 2006 and September 2016. Survival curve was calculated by Kaplan-Meier method. Prognostic factors for post-salvage lymphadenectomy overall survival (PSL-OS) were identified by univariate and multivariate analyses.

Results

The median disease-free survival (DFS) was 8 months. The median PSL-OS was 40 months (95% CI: 8.850-71.150). The 1-, 2-, 3- and 5-year PSL-OS rate were 87%, 58%, 52% and 41%, respectively. Univariate and multivariate analyses confirmed the initial TNM stage was the only independent prognostic factor for PSL-OS (P=0.000 by log-rank test, P=0.009 by Cox hazards model, HR 3.999, 95% CI: 1.413-11.316) among these patients.

Conclusions

PSL survival could be considerable for patients with early initial tumor stage. Prospective studies are warranted to clarify the value of salvage lymphadenectomy.

Salvage photodynamic therapy accompanied by extended lymphadenectomy for advanced esophageal carcinoma: A case report

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A case of esophageal cancer was treated with PDT after salvage Appleby operation.

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Salvage lymphadenectomy is a safer procedure than salvage esophagectomy.

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Salvage lymphadenectomy may be insufficient as a curative treatment.

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PDT is a novel promising option for control primary carcinoma.

Introduction

Salvage surgery for locoregional failures after definitive chemoradiotherapy (dCRT) for esophageal cancer is widely practiced, but treatment options complementing it are also needed due to the high morbidity and mortality and low rate of curative resection.

Presentation of case

A 58-year-old man with a surgical history of right upper lobectomy for lung cancer was diagnosed as having esophageal squamous cell carcinoma. Computed tomography revealed swelling of the lesser curvature lymph node, and it had invaded the stomach, the body and tail of the pancreas and the left gastric artery, splenic artery and celiac artery. The patient underwent definitive-dose radiation with chemotherapy. Complete response was attained for the primary tumor, but the metastatic lymph node infiltrating the stomach, pancreas and major vessels remained. Therefore, the Appleby operation was proposed to the patient and subsequently performed aiming at curability. However, the primary tumor recurred 38 months after surgery, so the novel modality of photodynamic therapy using talaporfin sodium and a diode laser was performed, and a complete response was attained for this lesion. The patient is alive at 50 months after the salvage Appleby operation.

Discussion and conclusion

Salvage lymphadenectomy for esophageal cancer may be insufficient as a curative treatment because of regrowth of the primary lesion. However, photodynamic therapy may be applicable as a curative treatment option for recurrence of the primary lesion after salvage lymphadenectomy.