An Editorial on Salvage Esophagectomy for Esophageal Cancer

Excerpt

In the last decades, the 5-years survival of locally advanced esophageal cancer has improved to 40-50% in multimodal treatment settings that involve chemo(radio)therapy in combination with esophagectomy.¹ Both neoadjuvant chemoradiotherapy and perioperative chemotherapy are applied in this context, which have been extensively compared. For adenocarcinoma, similar survival rates were demonstrated in the prematurely closed Neo-AEGIS trial that included patients with adenocarcinoma of the esophagus or gastro-esophageal junction, despite higher pathological complete response rates in the neoadjuvant chemoradiotherapy group.² For squamous cell carcinoma, a recent meta-analysis of 6 randomized controlled trials showed that neoadjuvant chemoradiotherapy (nCRT) achieves better survival than perioperative chemotherapy, as well as increased pathological response rates.³ In line with these results, nCRT followed by planned esophagectomy is the standard treatment for locally advanced esophageal adeno- or squamous cell carcinoma of the esophagus in many centers. As a substantial part of patients achieves a pathological complete response following chemoradiotherapy (i.e. almost 50% of squamous cell carcinomas and 16-20% of adenocarcinomas according to data from the CROSS trial⁴), surgery might be omitted in some patients. Definitive chemoradiotherapy (dCRT), however, is an option that is generally preserved for patients who are primarily ineligible for esophagectomy for multiple reasons (i.e. poor physical fitness, cT4b tumors, or patients who do not wish to undergo surgery). Various dCRT schemes are used worldwide, which mostly involve radiation doses of >50 Gy (as compared to the 41.4 Gy in the CROSS regimen). However, initial circumstances can change during or after the course of dCRT and, consequently, esophagectomy might be reconsidered. Although experts agree that salvage esophagectomy (i.e. esophagectomy after dCRT) is a highly complex procedure due to the extensive post-radiation fibrosis that is associated with high radiation doses and prolonged time until surgery, there seems to be a distinct group of patients with locoregional residual or recurrent disease that can benefit from this treatment. In an early meta-analysis of long-term outcomes following salvage esophagectomy after dCRT, salvage esophagectomy was associated with superior overall survival compared to second-line chemoradiotherapy, at the price of a perioperative mortality rate of 10%. Since the 3-year overall survival following salvage esophagectomy varied substantially in that study (17–58%), adequate patient selection already appeared to be key.⁵ …