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Indications and outcome of salvage surgery for oesophageal cancer

^a Department of Thoracic Surgery, Ste Marguerite University Hospital, Marseille, France
^b Intensive care Unit, Ste Marguerite University Hospital, Marseille, France
^c Department of Digestive Oncology, La Timone Hospital, Marseille, France
^d UMR 6020, IFR 48, University of the Mediterranean, Marseille, France

Received 30 July 2007; received in revised form 6 January 2008; accepted 16 January 2008.

^_* Corresponding author. Address: Department of Thoracic Surgery, Ste Marguerite Hospital, CHU Sud, 270 Bvd Ste Marguerite, 13274 Marseille Cedex 9, France. Tel.: +33 491 744 680; fax: +33 491 744 590. (Email: Pascal-alexandre.Thomas{at}mail.ap-hm.fr).

Objective: Some patients with localised oesophageal cancer are treated with definitive chemoradiotherapy (CRT) rather than surgery. A subset of these patients experiences local failure, relapse or treatment-related complication without distant metastases, with no other curative treatment option but salvage oesophagectomy. The aim of this study was to assess the benefit/risk ratio of surgery in such context. Methods: Review of a single institution experience with 24 patients: 18 men and 6 women, with a mean age of 59 years (±9). Histology was squamous cell carcinoma in 18 cases and adenocarcinoma in 6. Initial stages were cIIA (n = 5), cIIB (n = 1) and cIII (n = 18). CRT consisted of 2–6 sessions of the association 5-fluorouracil/cisplatin concomitantly with a 50–75 Gy radiation therapy. Salvage oesophagectomy was considered for the following reasons: relapse of the disease with conclusive (n = 11) or inconclusive biopsies (n = 7), intractable stenosis (n = 3), and perforation or severe oesophagitis (n = 3), at a mean delay of 74 days (14–240 days) following completion of CRT. Results: All patients underwent a transthoracic en-bloc oesophagectomy with 2-field lymphadenectomy. Thirty-day and 90-day mortality rates were 21% and 25%, respectively. Anastomotic leakage (p = 0.05), cardiac failure (p = 0.05), length of stay (p = 0.03) and the number of packed red blood cells (p = 0.02) were more frequent in patients who received more than 55 Gy, leading to a doubled in-hospital mortality when compared to that of patients having received lower doses. A R0 resection was achieved in 21 patients (87.5%). A complete pathological response (ypT0N0) was observed in 3 patients (12.5%). Overall and disease-free 5-year survival rates were 35% and 21%, respectively. There was no long-term survivor following R1–R2 resections. Functional results were good in more than 80% of the long-term survivors. Conclusion: Salvage surgery is a highly invasive and morbid operation after a volume dose of radiation exceeding 55 Gy. The indication must be carefully considered, with care taken to avoid incomplete resections. Given that long-term survival with a fair quality of life can be achieved, such high-risk surgery should be considered in selected patients at an experienced centre.

Key Words: Oesophageal neoplasms • Chemotherapy • Radiotherapy • Oesophagectomy