Salvage esophagectomy after definitive chemoradiotherapy for esophageal cancer

Abstract

Salvage esophagectomy is performed for esophageal cancer after definitive chemoradiotherapy. The clinical significance and safety of salvage surgery has not been well established. We reviewed 14 cases of salvage esophagectomy following definitive chemoradiotherapy from 1994 through 2005 and investigated complication rates and outcomes. Seven of 14 cases were completely resected with salvage surgery. Operation time and bleeding were greater in patients who experienced incomplete resection (R1/R2). Anastomosis leakage, pulmonary dysfunction and heart failure were recognized in four, two and one patients, respectively. The postoperative complications were more frequent (71.4%) in patients with incomplete resection (R1/R2) than in patients with complete resection (R0) (28.4%). Two patients with complete resection (R0) showed long-term survival. Salvage esophagectomy may be indicated when the tumor can be resected completely after definitive chemotherapy. However, all cases of T4 cancer cannot be resected completely, resulting in a high risk for complications and poor survival.

Salvage esophagectomy: safe therapeutic strategy?

“…However it must be emphasized that salvage esophagectomy represents one of the more complex variants of esophagectomy due to the scarring effects of radiotherapy upon the operative field (24). Thus previous surgeon volume-outcome effects observed for all esophagectomy are likely to be amplified in the setting of salvage esophagectomy (25).…”

Clinical significance of salvage esophagectomy for remnant or recurrent cancer following definitive chemoradiotherapy

“…Salvage esophagectomy has been indicated for such lesions. However, the surgical risk of this procedure is still considered to be extremely high, with high mortality and morbidity rates [9][10][11][12]. The effect of preoperative radiation on the development of postoperative complications, as well as its effect on patients' prognoses, is still unclear.…”

Multimodal Therapies for Upper Gastrointestinal Cancers – Past, Now, and Future

“…However, salvage surgery is a highly invasive and complex treatment leading to increased morbidity (50-79%) and in-hospital mortality (7-22%) as compared with those after neoadjuvant CRTx, due to the adverse events of predominantly respiratory complications and anastomotic leakage (Chao et al, 2009;Nakamura et al, 2004;M. Nishimura et al, 2007;Oki et al, 2007;Smithers et al, 2007;Swisher et al, 2002;Tachimori et al, 2009;Tomimaru et al, 2006). These hospital mortality rates are obviously higher than those for esophagectomy in Japan reported from specialized centers (2%) (Tachimori et al, 2009) or the nationwide registry (5%) (The Japan Esophageal Society).…”

“…Second, multivariate analysis revealed that the most significant factor associated with longterm survival was a R0 resection (Chao et al, 2009;Tomimaru et al, 2006). No patients left with gross or microscopic residual tumors after salvage surgery (R1/R2 resections) survived more than 24 months in any series (Chao et al, 2009;Nakamura et al, 2004;Oki et al, 2007;Swisher et al, 2002;Tachimori et al, 2009;Tomimaru et al, 2006). However, the R1/R2 resection rate has been substantially high, ranging from 15-50% (Chao et al, 2009;Nakamura et al, 2004;Oki et al, 2007;Swisher et al, 2002;Tachimori et al, 2009;Tomimaru et al, 2006), and the resection status cannot be confidently predicted before surgery or even during surgery because of the indistinct planes between tumor and fibrotic masses within the irradiated mediastinum.…”