Salvage Esophagectomy for Persistent or Recurrent Disease After Chemoradiation

Abstract

Neoadjuvant chemoradiation is currently used by many cancer centers as the initial treatment for locoregionally-advanced esophageal cancer, with many patients achieving clinical complete response. The choice to operate in a planned fashion as a component of trimodality therapy is often weighed against the option of a salvage approach, risk-stratifying patients to either modality is a matter of important surgical consideration. In this chapter, we will discuss the recent literature evaluating salvage surgery for esophageal cancer, separated by studies which evaluated this question in only adenocarcinoma, squamous cell carcinoma, or both. We will discuss the patient population, mortality, and morbidity of planned versus salvage strategies in each of the selected studies. In a broad view, adenocarcinoma patients undergoing salvage surgery appear to have acceptable morbidity and mortality compared to those with a planned trimodality strategy. The same cannot be said for patients with squamous tumors, who suffer more frequent perioperative events, especially in those who received higher radiation dose, suggesting that planned surgery may be safer in this population. These retrospective studies are conducted in a highly selected group of patients, and invariably contain selection bias in the compared groups; thus, findings must be interpreted with caution. The results from the ongoing SANO trial may help to guide clinical decisions regarding the optimal treatment strategy for esophageal cancer patients.