title: Indications and outcome of salvage surgery for oesophageal cancer.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Thoracic Surgery, Ste Marguerite University Hospital, Marseille, France.
authors.forename: Xavier-Benoit
authors.initials: XB
authors.lastname: D'Journo
authors.forename: Pierre
authors.initials: P
authors.lastname: Michelet
authors.forename: Laetitia
authors.initials: L
authors.lastname: Dahan
authors.forename: Christophe
authors.initials: C
authors.lastname: Doddoli
authors.forename: Jean-François
authors.initials: JF
authors.lastname: Seitz
authors.forename: Roger
authors.initials: R
authors.lastname: Giudicelli
authors.forename: Pierre A
authors.initials: PA
authors.lastname: Fuentes
authors.forename: Pascal A
authors.initials: PA
authors.lastname: Thomas
mesh_terms: D000368:Aged; D003131:Combined Modality Therapy; D004938:Esophageal Neoplasms / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D016629:Esophagectomy / Q000009:adverse effects; D005260:Female; D005541:Forced Expiratory Volume; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D018579:Patient Selection; D011788:Quality of Life; D012008:Recurrence; D012189:Retrospective Studies; D016879:Salvage Therapy / Q000009:adverse effects / Q000379:methods*; D016019:Survival Analysis; D016896:Treatment Outcome; D014797:Vital Capacity