Esophageal Cancer: Surgical Treatment of Esophageal Cancer – long term outcomes
Recurrent disease remains the leading cause of mortality following esophagectomy for esophageal carcinoma. While patterns of recurrence have been previously described, the prognostic impact of recurrence timing and site on post-recurrence survival (PRS) remains unclear. This study evaluated the impact of disease-free survival (DFS) duration and first recurrence site on PRS.
A multicentric retrospective cohort study was conducted including patients who experienced recurrence following esophagectomy with curative intent for esophageal carcinoma between 2012-2023. The association between DFS and PRS was modeled continuously on Cox regression and linearity was assessed using Martingale residuals.
Among 359 patients, 142 (39.6%) developed recurrence. Median follow-up was 40 months and median PRS was 12 months.
On Kaplan–Meier analysis, PRS differed by DFS category (<6, 6–24, and >24 months; p=0.022), with the longest survival observed among patients recurring >24 months after surgery (18.2% of patients; median PRS 19 months) (Figure 1A). When modeled continuously in Cox regression, each 6-month delay in DFS was associated with an 11% reduction in post-recurrence mortality (HR per 6 months 0.89, p=0.011) (Figure 1B).
Median PRS for isolated nodal recurrence (17.6% of patients) was 23 months and significantly longer than isolated local, isolated distant, or combined recurrences (p=0.003) (Figure 2). Isolated nodal recurrence was asymptomatic and detected at scheduled imaging in 22/25 (88%) patients.
After adjustment for preoperative and pathologic variables, DFS >24 months and isolated nodal recurrence independently predicted longer PRS (HR 0.49, p=0.005 and HR 0.44, p=0.003, respectively).
Among patients with recurrent esophageal carcinoma after esophagectomy, isolated nodal recurrence and DFS >24 months independently predicted prolonged PRS. These findings may help refine postoperative surveillance strategies and guide selection of patients most likely to benefit from salvage therapy.
Ofek Zemer, Ran Orgad, H. Merin et al.· Diseases of the esophagus· 0 citations
Esophageal Cancer: Other
An 84-year-old male had previously undergone a three-field esophagectomy with gastric pull-up reconstruction for stage I adenocarcinoma of the distal esophagus 14 years earlier. He remained disease-free during long-term follow-up. He subsequently presented with progressive dysphagia and mild, unintentional weight loss. Upper gastrointestinal endoscopy and endoscopic ultrasound demonstrated a stage II adenocarcinoma of the gastric antrum arising within the gastric conduit. Positron emission tomography–computed tomography demonstrated no evidence of metastatic disease. Comprehensive geriatric assessment was performed and confirmed that the patient was functionally independent, with preserved physiological reserve and no major contraindications to oncologic treatment or surgical intervention. His case was discussed at a multidisciplinary team meeting. The patient’s goals of care and treatment preferences were carefully explored, and upfront surgical management with curative intent was recommended. Several surgical strategies were considered. These included total gastrectomy of the gastric conduit with reconstruction using colon transposition or small-bowel supercharged reconstruction, as well as a more limited resection in the form of antrectomy. While total gastrectomy would have ensured maximal oncologic clearance, it may be associated with significant operative complexity and potential morbidity, particularly in the context of advanced age and prior extensive upper gastrointestinal surgery. After careful consideration of oncologic feasibility, technical factors, and patient-specific risk, a limited antrectomy with preservation of the right gastroepiploic artery was selected in order to maintain conduit vascularity and minimize surgical trauma. Surgery was performed successfully, with meticulous preservation of the right gastroepiploic artery supplying the gastric conduit. Adequate oncologic resection margins were achieved. The postoperative course was uneventful, with no surgical or medical complications, and the patient recovered well. Learning point: Secondary gastric malignancy within a gastric pull-up conduit is a rare but clinically significant late complication following esophagectomy. Management requires individualized decision-making, balancing oncologic principles with patient factors and complex reconstructive considerations. In selected patients, limited resection with preservation of conduit blood supply can provide a safe and effective surgical option, emphasizing the importance of multidisciplinary evaluation and tailored surgical strategy.
H. Kashtan, Y. Feferman, Daniel Solomon· Diseases of the esophagus· 0 citations
