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J Thorac Cardiovasc Surg 2002;123:175-183
© 2002 The American Association for Thoracic Surgery

General Thoracic Surgery

Salvage esophagectomy for recurrent tumors after definitive chemotherapy and radiotherapy

From the Department of Thoracic and Cardiovascular Surgery,^a Department of Radiation Oncology,^b and Department of Gastrointestinal Oncology,^c The University of Texas M.D. Anderson Cancer Center, Houston, Tex.

Received for publication May 14, 2001. Revisions requested June 15, 2001; revisions received July 18, 2001. Accepted for publication July 18, 2001. Address for reprints: Stephen G. Swisher, MD, The University of Texas M.D. Anderson Cancer Center, Department of Thoracic and Cardiovascular Surgery, 1515 Holcombe Blvd, Box 445, Houston, TX 77030 (E-mail: sswisher{at}mdanderson.org).

Objectives: Some patients and oncologists choose to treat localized esophageal cancer with definitive chemotherapy and radiation therapy rather than surgery. A subset of these patients have local relapse without distant metastases and therefore have no other curative intent treatment option but salvage esophagectomy.
Methods: We reviewed our experience with salvage esophagectomy from 1987 to 2000 at M.D. Anderson Cancer Center (n = 13, salvage after chemotherapy and radiotherapy group) and compared the data with those of patients receiving esophagectomy in a planned fashion 4 to 6 weeks after preoperative chemotherapy and radiation therapy (n = 99, preoperative chemotherapy and radiotherapy group).
Results: Increases in morbidity were seen after resection in the salvage after chemotherapy and radiotherapy group relative to the preoperative chemotherapy and radiotherapy group: mechanical ventilation (9.0 days vs 3.3 days, P = .08), intensive care unit stay (11.2 days vs 5.1 days, P = .07), hospital stay (29.4 days vs 18.4 days, P = .03), and anastomotic leak rates (5/13 [39%] vs 7/99 [7%], P = .005). Operative mortality (within 30 days) also tended to be increased statistically nonsignificantly (2/13 [15%] vs 6/99 [6%], P = .2). Salvage esophagectomy resulted in long-term survival (25% 5-year survival) in a subset of patients. Improved survival after salvage esophagectomy was associated with early pathologic stage (T1 N0, T2 N0), prolonged time to relapse, and R0 surgical resection.
Conclusion: Patients who undergo salvage esophagectomy for relapse of tumor after definitive chemoradiation therapy have increased morbidity, mortality, and hospital use relative to patients undergoing planned esophagectomy after preoperative chemoradiation. Nevertheless, long-term survival can be achieved in this group, and such treatment should be considered for carefully selected patients at an experienced center.

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