Salvage or planned esophagectomy after chemoradiation therapy for locally advanced esophageal cancer – a review

Abstract

Definitive chemoradiation (without esophagectomy) and neoadjuvant chemoradiation followed by planned esophagectomy are commonly used treatments for locally advanced esophageal cancer. These two treatment strategies have similar survival outcomes, so the value of planned esophagectomy is debated. However, persistence or recurrence of local disease is not uncommon after definitive chemoradiation. Salvage esophagectomy for isolated local failures of definitive chemoradiation is an option for selected patients. In this article we review the debate over definitive chemoradiation versus neoadjuvant chemoradiation and surgery, and then restate the argument in terms of salvage versus planned esophagectomy. Although both forms of esophagectomy are done in the setting of previous chemoradiation, they are different in several ways. Salvage esophagectomy appears to be a more morbid operation than planned esophagectomy. Surgeons supportive of the salvage esophagectomy strategy face the challenge of reducing its postoperative mortality.

Clinical outcome of esophageal cancer patients with history of gastrectomy

“…Surgery to remove thoracic esophageal cancer is one of the most stressful therapeutic modalities and the development of chemotherapy and radiotherapy has occasionally shown an equivalent clinical benefit. Thus, the surgical indication for esophageal cancer has recently been discussed more seriously with respect to its survival benefit [11,12]. There have been many studies concerning esophageal cancers after gastrectomy, which revealed some differences in the clinicopathological features in comparison with esophageal cancer without a history of gastrectomy, such as for sex [13], tumor location [2,5,13], and multiple cancers [14].…”

Avaliação das complicações da esofagectomia de resgate na terapêutica cirúrgica do câncer de esôfago avançado

“…However it is well known that the morbidity of the rescue esophagectomy is higher when compared to the conventional esophagectomy after neoadjuvant therapy 20,24,30 . Some series have demonstrated greater tissue injury in patients undergoing the rescue esophagectomy, since the total dose used in the initial curative chemoradiation is higher (50 to 60 Gray), compared to 30 to 40 Gray used in the group of patients who try neoadjuvant therapy 24,28,30 . It is also relevant the fact that the conventional planned esophagectomy has lesser time interval between completion of chemoradiation and surgery, usually 20 to 30 days.…”

“…The rescue esophagectomy has currently been disclosed once the exclusive chemoradiation presents an inherent failure of up to 60% with median survival of 12 to 18 months and a five-year survival rate of 10 to 30% 5,13,15,23,24,30,33 . However it is well known that the morbidity of the rescue esophagectomy is higher when compared to the conventional esophagectomy after neoadjuvant therapy 20,24,30 .…”

“…It is also relevant the fact that the conventional planned esophagectomy has lesser time interval between completion of chemoradiation and surgery, usually 20 to 30 days. The indication of the rescue esophagectomy is often late, usually months, allowing enough time to develop intense fibrosis, making it difficult to dissect the esophagus and mediastinal structures and contributing to its greater morbidity 13,20,24,30,31 . In this series all patients underwent the surgery within about six months after chemoradiation.…”

Esofagectomia de resgate após quimiorradioterapia radical exclusiva: resultados do departamento de cirurgia abdôminopélvica do Instituto Nacional de Câncer

“…Entretanto, o controle locorregional é pobre com taxas de recidiva local relatada na literatura de 40-60%. A esofagectomia de resgate fornece a única possibilidade de cura para pacientes selecionados com recorrência tumoral ou persistência de doença após a quimiorradioterapia exclusiva, com taxas de sobrevida em cinco anos de aproximadamente 25% 10 . Do ponto de vista teórico, a cirurgia de resgate é dotada de maior dificuldade técnica e morbimortalidade operatória, devido à alta dose de radiação aplicada no leito tumoral e ao maior intervalo de tempo entre o término do tratamento Vol.…”