Advertisement

Journal of Gastroenterology

, Volume 46, Issue 11, pp 1284–1291 | Cite as

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

  • Masaru MoritaEmail author
  • Ryuichi Kumashiro
  • Yuichi Hisamatsu
  • Ryota Nakanishi
  • Akinori Egashira
  • Hiroshi Saeki
  • Eiji Oki
  • Takefumi Ohga
  • Yoshihiro Kakeji
  • Shunichi Tsujitani
  • Takeharu Yamanaka
  • Yoshihiko Maehara
Original Article—Alimentary Tract

Abstract

Background

The purpose of this study was to clarify the effect of preoperative chemoradiotherapy (CRT) for esophageal cancer on the postoperative course, and to determine the clinical significance of salvage esophagectomy after definitive CRT.

Methods

Based on their preoperative treatment, 477 patients with esophageal cancer were classified into three groups: 253 patients who received surgery alone (Group I), 197 who received planned CRT (30–45 Gy, Group II), and 27 who received a salvage esophagectomy (radiation ≥60 Gy, Group III).

Results

Postoperative complications developed in 25, 40, and 59% of the patients in Groups I, II, and III, respectively, with pulmonary complications developing in 10, 15, and 30%, and anastomotic leakage developing in 13, 23, and 37%, respectively. Mortality rates were 2.4, 2.0, and 7.4%, respectively. Multivariate analysis revealed preoperative therapy to be an independent factor associated with postoperative risks: the odds ratios (ORs) of Groups II and III compared to Group I were 1.8 and 4.0 for pulmonary complications, while they were 1.9 and 2.8, respectively, for anastomotic leakage. No critical complications developed in the 14 patients who received salvage surgery performed with strict surgical indications after 2005. The survival of Group III was not significantly different from that of Groups I and II. Most patients who received an R1/R2 resection after definitive CRT died within 2 years after salvage surgery.

Conclusions

Preoperative CRT is associated with postoperative complications especially in patients with R2 resection, while long-term survival can be achieved after R0 resections. Salvage surgery should be considered for carefully selected patients in whom R0 resection can be achieved.

Keywords

Esophageal cancer Salvage esophagectomy Definitive chemoradiotherapy 

Notes

Acknowledgments

We thank Brian Quinn for assisting with the preparation of the manuscript. This work was supported in part by a Grant-in-Aid from the Ministry of Education, Culture, Sport, Science and Technology of Japan.

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Wu PC, Posner MC. The role of surgery in the management of oesophageal cancer. Lancet Oncol. 2003;4:481–8.PubMedCrossRefGoogle Scholar
  2. 2.
    Earlam R, Cunha-Melo JR. Oesophogeal squamous cell carcinoms: II. A critical view of radiotherapy. Br J Surg. 1980;67:457–61.PubMedCrossRefGoogle Scholar
  3. 3.
    Müller JM, Erasmi H, Stelzner M, Zieren U, Pichlmaier H. Surgical therapy of oesophageal carcinoma. Br J Surg. 1990;77:845–57.PubMedCrossRefGoogle Scholar
  4. 4.
    Cooper JS, Guo MD, Herskovic A, Macdonald JS, Martenson JA Jr, Al-Sarraf M, et al. Chemoradiotherapy of locally advanced esophageal cancer: long-term follow-up of a prospective randomized trial (RTOG 85-01). Radiation Therapy Oncology Group. JAMA. 1999;281:1623–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Ohtsu A, Boku N, Muro K, Chin K, Muto M, Yoshida S, et al. Definitive chemoradiotherapy for T4 and/or M1 lymph node squamous cell carcinoma of the esophagus. J Clin Oncol. 1999;17:2915–21.PubMedGoogle Scholar
  6. 6.
    Kato H, Sato A, Fukuda H, Kagami Y, Udagawa H, Togo A, et al. A phase II trial of chemoradiotherapy for stage I esophageal squamous cell carcinoma: Japan Clinical Oncology Group Study (JCOG9708). Jpn J Clin Oncol. 2009;39:638–43.PubMedCrossRefGoogle Scholar
  7. 7.
    Hironaka S, Ohtsu A, Boku N, Muto M, Nagashima F, Saito H, et al. Nonrandomized comparison between definitive chemoradiotherapy and radical surgery in patients with T(2–3)N(any) M(0) squamous cell carcinoma of the esophagus. Int J Radiat Oncol Biol Phys. 2003;57:425–33.PubMedCrossRefGoogle Scholar
  8. 8.
    Ishikura S. Long-term toxicity after definitive chemoradiotherapy for squamous cell carcinoma of the thoracic esophagus. J Clin Oncol. 2003;21:2697–702.PubMedCrossRefGoogle Scholar
  9. 9.
    Swisher SG, Wynn P, Putnam JB, Mosheim MB, Correa AM, Komaki RR, et al. Salvage esophagectomy for recurrent tumors after definitive chemotherapy and radiotherapy. J Thorac Cardiovasc Surg. 2002;123:175–83.PubMedCrossRefGoogle Scholar
  10. 10.
    Nakamura T, Hayashi K, Ota M, Eguchi R, Ide H, Takasaki K, et al. Salvage esophagectomy after definitive chemotherapy and radiotherapy for advanced esophageal cancer. Am J Surg. 2004;188:261–6.PubMedCrossRefGoogle Scholar
  11. 11.
    Oki E, Morita M, Kakeji Y, Ikebe M, Sadanaga N, Egasira A, et al. Salvage esophagectomy after definitive chemoradiotherapy for esophageal cancer. Dis Esophagus. 2007;20:301–4.PubMedCrossRefGoogle Scholar
  12. 12.
    Tachimori Y, Kanamori N, Uemura N, Hokamura N, Igaki H, Kato H. Salvage esophagectomy after high-dose chemoradiotherapy for esophageal squamous cell carcinoma. J Thorac Cardiovasc Surg. 2009;137:49–54.PubMedCrossRefGoogle Scholar
  13. 13.
    Ando N, IIzuka T, Ide H, Shinoda M, Nishimaki T, Takiyama W, et al. Surgery plus chemotherapy compared with surgery alone for localized squamous cell carcinoma of the thoracic esophagus: a Japan Clinical Oncology Group Study—JCOG9204. J Clin Oncol. 2003;21:4592–6.PubMedCrossRefGoogle Scholar
  14. 14.
    Kuwano H, Nishimura N, Ohtsu A, Kato H, Kitagawa Y, Tamai S, et al. Guidelines for diagnosis and treatment of carcinoma of the esophagus, April 2007 edition: part II, edited by the Japan Esophageal Society. Esophagus. 2008;5:117–32.CrossRefGoogle Scholar
  15. 15.
    Morita M, Nakanoko T, Kubo N, Fujinaka Y, Ikeda K, Egashira A, et al. Two-stage operation for high-risk patients with thoracic esophageal cancer: an old operation revisited. Ann Surg Oncol. doi: 10.1245/s10434-011-1654-y (On line 2011, March 16).
  16. 16.
    Morita M, Yoshida R, Ikeda K, Egashira A, Oki E, Sadanaga N, et al. Advances in esophageal cancer surgery in Japan: an analysis of 1000 consecutive patients treated at a single institute. Surgery. 2008;143:499–508.PubMedCrossRefGoogle Scholar
  17. 17.
    Japan Esophageal Society. Japanese classification of esophageal cancer. 10th ed. Tokyo: Kanehara; 2008.Google Scholar
  18. 18.
    UICC. TNM classification of malignant tumors. 7th ed. New York: Wiley; 2009.Google Scholar
  19. 19.
    Schemper M, Smith TL. A note on quantifying follow-up in studies of failure time. Control Clin Trials. 1996;17:343–6.PubMedCrossRefGoogle Scholar
  20. 20.
    Gardner-Thorpe J, Hardwick RH, Dwerryhouse SJ. Salvage oesophagectomy after local failure of definitive chemoradiotherapy. Br J Surg. 2007;94:1059–66.PubMedCrossRefGoogle Scholar
  21. 21.
    Morita M, Masuda T, Okada S, Yoshinaga K, Saeki H, Tokunaga E, et al. Preoperative chemoradiotherapy for esophageal cancer: factors associated with clinical response and postoperative complications. Anticancer Res. 2009;29:2555–62.PubMedGoogle Scholar
  22. 22.
    Saeki H, Masuda T, Okada S, Ando K, Sugiyama M, Yoshinaga K, et al. Impact of perioperative peripheral blood values on postoperative complications after esophageal surgery. Surg Today. 2010;40:626–31.PubMedCrossRefGoogle Scholar
  23. 23.
    Tsutsui S, Sonoda K, Sumiyoshi K, Kitamura K, Toh Y, Kitamura M, et al. Prognostic significance of immunological parameters in patients with esophageal cancer. Hepatogastroenterology. 1996;43:501–9.PubMedGoogle Scholar
  24. 24.
    Tomimaru Y, Yano M, Takachi K, Miyashiro I, Ishihara R, Nishiyama K, et al. Factors affecting the prognosis of patients with esophageal cancer undergoing salvage surgery after definitive chemoradiotherapy. J Surg Oncol. 2006;93:422–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Morita M, Yoshida R, Ikeda K, Egashira A, Oki E, Sadanaga N, et al. Acute lung injury following an esophagectomy for esophageal cancer, with special reference to the clinical factors and cytokine levels of peripheral blood and pleural drainage fluid. Dis Esophagus. 2008;21:30–6.PubMedGoogle Scholar
  26. 26.
    Morita M, Nakanoko T, Fujinaka Y, Kubo N, Yamashita N, Yoshinaga K, et al. In-hospital mortality after a surgical resection for esophageal cancer: analyses of the associated factors and historical changes. Ann Surg Oncol. 2011;18:1757–65.PubMedCrossRefGoogle Scholar
  27. 27.
    Kato H, Miyazaki T, Nakajima M, Fukuchi M, Manda R, Kuwano H. Value of positron emission tomography in the diagnosis of recurrent oesophageal carcinoma. Br J Surg. 2004;91:1004–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer 2011

Authors and Affiliations

  • Masaru Morita
    • 1
    Email author
  • Ryuichi Kumashiro
    • 1
  • Yuichi Hisamatsu
    • 1
  • Ryota Nakanishi
    • 1
  • Akinori Egashira
    • 1
  • Hiroshi Saeki
    • 1
  • Eiji Oki
    • 1
  • Takefumi Ohga
    • 1
  • Yoshihiro Kakeji
    • 1
  • Shunichi Tsujitani
    • 1
  • Takeharu Yamanaka
    • 2
  • Yoshihiko Maehara
    • 1
  1. 1.Department of Surgery and ScienceGraduate School of Medical Sciences, Kyushu UniversityFukuokaJapan
  2. 2.Cancer Biostatistics LaboratoryInstitute for Clinical Research, National Kyushu Cancer CenterFukuokaJapan

Personalised recommendations