New Trend of Surgery in Locally Advanced Esophageal Squamous Cell Carcinoma Patients

The treatment of locally advanced esophageal squamous cell carcinoma is still controversial. Although, preoperative chemoradiation, followed by esophagectomy is the standard treatment, morbidity and patients’ quality of life problems after an esophagectomy are still considerable. Since a good pathologic complete response rate in patients after preoperative chemoradiation, a wait and see policy (with active surveillance) has been introduced as a new alternative approach after chemoradiation. Active surveillance involves imaging and biopsy evaluations in patients after chemoradiation to detect residual or recurrent tumors. If there are no residual tumors, observation is considered. Surgery is reserved for patients who present with residual tumors or locoregional recurrence after surveillance to achieve complete resection (salvage esophagectomy). Based on evidence from recent studies, surveillance with salvage esophagectomy is a treatment option for locally advanced esophageal squamous cell carcinoma patients achieving a clinical complete response after chemoradiation.

Salvage Robotic-Assisted Thoracoscopic Esophagectomy after Definitive Chemoradiotherapy for Clinical T4b Esophageal Cancer: A Case Report

BackgroundAlthough twenty years have passed since the start of robot-assisted thoracoscopic esophagectomy, salvage esophagectomy by robotic-assisted surgery has not yet been introduced by almost surgeons. Theoretically, robot-assisted thoracoscopic esophagectomy (RATE) increases operative precision and maneuverability within the narrow space of the mediastinum. However, surgeons have doubted that RATE is indicated for patients with tumor invasion of adjacent vital organs clinically (cT4b) or patients with scar tissue from definitive chemoradiotherapy. Herein, we report our case of salvage RATE for cT4b thoracic esophageal cancer which invaded to the left main bronchus before definitive chemoradiotherapy.Case presentationA man in his 60’s with middle thoracic esophageal cancer [cT4b (left main bronchus) N1 M0 cStage IIIC] received definitive chemoradiotherapy (fluorouracil and cisplatin, total radiation dose of 60 Gy). After the chemoradiotherapy, upper gastrointestinal endoscopy revealed a residual primary tumor, and we performed robotic-assisted thoracoscopic subtotal esophagectomy and gastric tube reconstruction via a retrosternal route with three-field lymphadenectomy. Although it was difficult to dissect the tumor from adjacent organs, especially in the left main bronchus and pericardium, due to the scarring after definitive chemoradiotherapy, R0 surgery was achieved. With RATE, the high-resolution three-dimensional images, stable surgical field and stable motion are considerable advantages for salvage esophagectomy for cT4b tumors. At present (30 months after surgery), the patient’s performance status is 0 and he is alive without a recurrence. ConclusionsRobot-assisted thoracoscopic esophagectomy provided considerable advantages for salvage esophagectomy after definitive chemoradiotherapy for a cT4b tumor.

260 FAILURE TO CURE IN PATIENTS UNDERGOING ESOPHAGEAL CARCINOMA SURGERY: HOSPITAL OF SURGERY INFLUENCES PROSPECTS FOR CURE. A NATIONWIDE COHORT STUDY.

Failure to cure is a composite outcome measure that could be used for hospital comparison in surgical esophageal carcinoma care. It was first described by Clavien et al. in 1992 and was defined as the event where the procedural purpose was not fulfilled. The aim of the current study was to describe failure to cure in terms of incidence, hospital variation, and as an outcome parameter for salvage esophagectomy (surgical resection after definitive chemoradiotherapy). Methods All patients registered in the Dutch Upper GI Cancer Audit (DUCA) who underwent potentially curative esophageal carcinoma surgery between 2011 and 2018, were included in this nationwide cohort study. Failure to cure was defined as: 1) no esophagectomy due to intra-operative metastasis or locally irresectable tumour, 2) macroscopically or microscopically incomplete resection (pR1, R2), or 3) 30-day or in-hospital mortality. Association of patient, tumor and hospital characteristics with failure to cure was analyzed using multivariable logistic regression in the total population and in salvage surgery patients. Hospital variation was evaluated using multivariable regression and displayed in a case-mix corrected funnelplot. Results Some 6,045 patients from 22 hospitals were included of whom 701 (11.6%) had failure to cure (hospital variation [5.9%–19.0%]). Higher age, more preoperative weight loss, higher ASA-score, junctional tumors, higher T-stage and N-stage, no neoadjuvant chemoradiotherapy, and resection before 2014 were associated with failure to cure. After case-mix correction, 2 hospitals had statistically significant lower than expected failure to cure percentages, and 2 hospitals had higher percentages (figure1). In the patients undergoing salvage esophagectomy (n = 151), the failure to cure percentage was 32.5%. This was 27.6% in high-volume hospitals (>40 annual esophagectomies) and 47.6% in medium-volume hospitals (20–40 annual esophagectomies) (p = 0.03). Conclusion This was the first study to describe failure to cure for oesophageal carcinoma patients. The incidence of failure to cure was 11.6%, which is an important prognostic parameter for patients that should be used for expectation management. Given the significant hospital variation in the incidence of failure to cure, improvement is needed. Since salvage procedures are more often successful in high-volume hospitals, further centralization of this technically challenging procedure is warranted.

326 DEFINITIVE CHEMORADIOTHERAPY COMPARED TO NEOADJUVANT CHEMORADIOTHERAPY WITH ESOPHAGECTOMY FOR LOCO-REGIONAL ESOPHAGEAL CANCER: NATIONAL POPULATION-BASED COHORT STUDY

Ongoing randomized controlled trials seek to evaluate the potential organ-preservation strategy of definitive chemoradiotherapy as a primary treatment for esophageal cancer. This population-based cohort study aimed to assess survival following definitive chemoradiotherapy (DCR) with or without salvage esophagectomy (SALV) in the treatment of esophageal cancer. Methods Data from the National Cancer Database (NCDB) from 2004 to 2015, was used to identify patients with non-metastatic esophageal cancer receiving either DCR (n = 5,977) or neoadjuvant chemoradiotherapy with planned esophagectomy (NCRS) (n = 13,555). Propensity score matching (PSM) and multivariable analyses were used to account for treatment selection bias. Subset analyses compared patients receiving salvage esophagectomy after DCR (SALV) with NCRS. Results Comparison of baseline demographics of the unmatched cohort revealed that patients receiving NCRS were younger, had a lower burden of medical comorbidities, lower proportion of squamous cell carcinoma (SCC) and more positive lymph nodes. Following matching, NCRS was associated with significantly improved survival compared with DCR (HR: 0.60, 95% Confidence Interval (CI): 0.57—0.63, p < 0.001), which persisted in subset analyses of patients with adenocarcinoma (HR: 0.60, 95%CI: 0.56—0.63, p < 0.001) and SCC (HR: 0.58, 95%CI: 0.53—0.63, p < 0.001). There was no difference in overall survival between SALV and NCRS (HR: 1.00, 95%CI: 0.90—1.11, p = 1.0). Conclusion Surgery remains an integral component of the management of patients with esophageal cancer. Neoadjuvant therapy followed by planned esophagectomy appears to remain the optimum curative treatment regime in patients with loco-regional esophageal cancer.