Salvage Lymphadenectomy for Recurrent Esophageal Cancer After Chemoradiotherapy

Although salvage esophagectomies are widely performed, reports on salvage lymphadenectomy (SL) are few. We review our SL cases to clarify the indications. Fifty-five patients with esophageal cancer underwent chemoradiotherapy or radiotherapy, including 3 patients with single lymph node (LN) recurrences and one with allochronic double cervical node recurrence. Our department removed 5 recurrent LNs from these 4 patients. In Case 1, right supraclavicular LN was judged to be metastatic and R0 resection was carried out; he is alive without recurrence. In Case 2, we found, allochronically, metastases in his left cervical paraesophageal LN and left supraclavicular LN; residual tumors were R1 in both lesions. He is alive despite esophageal recurrence. In Case 3, a lymphadenectomy was performed on his thoracic para-aortic LN; however, tumor was removed incompletely, and he died 4 months after SL from disease progression. In Case 4, a subcarinal LN was thought to be metastatic, and was removed but no malignant tissues detected. He died 17 months after SL from pneumonia. Our experiences suggest that some patients survive relatively long with SL. Moreover, molecular examination of resected lesions could guide subsequent therapies. SL might be more widely used for these patients if not otherwise contraindicated.Key words: Esophageal cancer, salvage lymphadenectomy, Salvage surgery, Esophagectomy, ChemoradiotherapyEsophageal cancer is the eighth most common form of cancer worldwide, and is one of the most difficult malignancies to cure.¹ Excluding cases with severe concomitant diseases, surgery is the best modality to cure esophageal cancer.² However, many patients with esophageal cancer have concomitant diseases that are associated with alcohol and tobacco consumption, such as chronic obstructive pulmonary disease, liver cirrhosis, and synchronous cancers of the lung or head and neck region.³ For patients with such concomitant diseases, chemoradiotherapy (CRT) is usually performed to cure esophageal cancer. For unresectable advanced-stage tumors, CRT is also used, and sometimes has favorable results. The Radiation Therapy Oncology Group trial (RTOG 85-01) has established CRT without surgery as one standard for definitive treatment.⁴ Many patients and oncologists have accepted the nonsurgical approach with CRT as definitive therapy for esophageal carcinoma. Although complete response (CR) rates are high and short-term survival is favorable after definitive CRT, locoregional disease persists or recurs in 40–60% of patients.⁵ From Japan, a phase II study of CRT for Stage II–III esophageal squamous cell carcinoma (JCOG9906)⁶ found a CR rate of 62.2%, with 34.2% patients having residual or locoregional recurrence without distant metastasis after CRT.For resectable residual or recurrent lesions after definitive CRT, surgical excision is the only curative modality. Therefore, such operations are called salvage surgery. In Japan, salvage surgery is defined as a procedure for recurrent or residual cancer after definitive CRT (RT > 50 Gy)⁷ and thought to be the only curative method. Conversely, salvage surgery is widely considered elsewhere to be a type of palliative surgery—the excision of tissue to reduce the risk of death due to physiologic derangement. Although salvage esophagectomy is performed in many institutions in Japan,^8–13 reports on salvage lymphadenectomy (SL) are still few.^14,15 In this article, we review our SL cases, and examine indications for this kind of surgery.