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Past
Definitive chemoradiotherapy, 50 Gy or higher, is the most important treatment modality for organ preservation in patients with esophageal squamous cell carcinoma. If cancer cells remain or recur after definitive chemoradiotherapy, salvage surgery is the only remaining treatment option. However, salvage surgery is associated with a higher rate of postoperative morbidity, such as pulmonary complications, and mortality compared with non-salvage surgery.1
For esophageal cancer, especially squamous cell carcinoma that frequently metastasizes to the upper mediastinal and cervical lymph nodes, three-field lymph node dissection in the cervical, thoracic, and abdominal regions is associated with better prognosis.2
Present
Since extensive lymph node dissection increases the risk of postoperative complications, only the necessary lymph nodes should be dissected, according to each case. Unfortunately, diagnostic accuracy of metastasis for regional lymph nodes before initial treatment is not so high even in positron emission tomography/computed tomography (PET/CT). Thus, an accurate diagnosis of the extent of truly positive lymph nodes is difficult without observing changes over time. Unlike neoadjuvant chemoradiotherapy, dynamic changes in lymph node size and properties could be evaluated over time before and after initial definitive chemoradiotherapy with relatively long and frequent follow-up. Therefore, selective lymphadenectomy of only clinically positive lymph nodes may contribute to obtaining good short-term surgical outcome and long-term oncological outcome in salvage esophagectomy after definitive chemoradiotherapy.3
Future
An organ-preserving therapy based on neoadjuvant chemoradiotherapy followed by active surveillance has been developed in recent years.4 If salvage surgery that is both safe and has good long-term outcomes can be performed, it may become more important to compare definitive chemoradiotherapy with neoadjuvant chemoradiotherapy followed by active surveillance in a randomized controlled trial setting.
References
Faiz Z, Dijksterhuis WPM, Burgerhof JGM, et al. A meta-analysis on salvage surgery as a potentially curative procedure in patients with isolated local recurrent or persistent esophageal cancer after chemoradiotherapy. Eur J Surg Oncol. 2019;45(6):931–40.
Udagawa H, Ueno M, Shinohara H, et al. The importance of grouping of lymph node stations and rationale of three-field lymphoadenectomy for thoracic esophageal cancer. J Surg Oncol. 2012;106(6):742–7.
Mayanagi S, Haneda R, Inoue M, et al. Selective lymphadenectomy for salvage esophagectomy in patients with esophageal squamous cell carcinoma. Ann Surg Oncol. 2022. https://doi.org/10.1245/s10434-022-11625-x.
Eyck BM, van der Wilk BJ, Noordman BJ, et al. Updated protocol of the SANO trial: a stepped-wedge cluster randomised trial comparing surgery with active surveillance after neoadjuvant chemoradiotherapy for oesophageal cancer. Trials. 2021;22(1):345.
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Mayanagi, S., Haneda, R., Inoue, M. et al. ASO Author Reflections: Safety and Curability of Lymphadenectomy for Salvage Esophagectomy. Ann Surg Oncol 29, 4871 (2022). https://doi.org/10.1245/s10434-022-11661-7
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DOI: https://doi.org/10.1245/s10434-022-11661-7