Salvage surgery may improve survival in local recurrence of esophageal cancer

1. The use of salvage surgery in locoregional recurrence of esophageal cancer following chemoradiotherapy demonstrated significantly increased survival compared to those who were unable to undergo salvage surgery.

Evidence Rating Level: 3 (Average)

Study Rundown: One of the most common approaches to the treatment of localized esophageal carcinoma is either chemoradiotherapy followed by surgery (aka trimodality therapy) or definitive chemotherapy (bimodality therapy, BMT). Previous studies have found that patients on BMT experience frequent local relapses, which may be treated with salvage surgical therapy. However, the current role of active surveillance for patients with BMT is unknown. The purpose of this study was to evaluate the timing and outcome of patients undergoing active surveillance following BMT for esophageal cancer.

At the conclusion of this retrospective cohort study of over 270 esophageal cancer patients, the authors found that local recurrence occurred in 23.2% (n=64) of patients, with the greatest risk of local recurrences occurring 2-3 years following BMT. Of the patients with local recurrence, 36% (n=23) of patients underwent salvage surgery therapy. Survival analysis demonstrated median overall survival of 58.6 months in patients that underwent salvage therapy, which was significantly increased from those who were unable to undergo salvage (9.5 months). This was the largest cohort of BMT patients to date and the findings provide strong support for the use of salvage therapy for patients with local recurrence following BMT and also support the role of vigilant surveillance for at least 24 months following definitive therapy. However, no cost analysis was performed, which may reduce the feasibility of a vigilant surveillance program.

Click to read the study in Journal of Clinical Oncology

Relevant Reading: Locoregional failure rate after preoperative chemoradiation of esophageal adenocarcinoma and the outcomes of salvage strategies

In-Depth [retrospective cohort]: This retrospective cohort study included a total of 276 patients with esophageal cancer who were treated with definitive bimodality chemotherapy (BMT). The primary outcomes were local relapse and distant metastases, and the salvage treatment for patients with local relapse only. Median follow-up time was 54.3 months. At the conclusion of the study, of the 276 patients, 23.3% (n=64) were locoregional relapses only, 43.5% (n=120) distant metastasis without locoregional recurrence, and 33.3% (n=92) did not relapse. 91% and 98% of local recurrences occurred within 2 and 3 years following BMT, respectively. 36% (n=23) of patients with local recurrence only underwent salvage surgery with median overall survival of 58.6 months (95% CI, 28.8 to not reached) compared to 9.5 months (95% CI, 7.8 to 13.3) for those unable to undergo surgery.

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