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Outcomes of Salvage Curative Intent Therapy for Recurrences of Esophago-Gastric Adenocarcinoma
Monisha Sudarshan*1, Thierry Alcindor3, Steven Ades2, Abdullah Aloraini1, Marie Vanhuyse3, Jamil Asselah3, Marc David4, Dominique Frechette5, Michael P. Thirlwell3, Lorenzo E. Ferri1
1Thoracic Surgery, McGill University, Montreal, QC, Canada; 2Oncology, University of Vermont, Burlington, VT; 3Oncology, McGill University, Montreal, QC, Canada; 4Radiation Oncology, McGill University, Montreal, QC, Canada; 5Oncology, Gatineau Hospital, Hull, QC, Canada
PURPOSE: Our objective was to characterize the isolated loco-regional and non-regional lymph node (LN) recurrences and outcomes after salvage therapy for esophageal and esophagogastric junction (EGJ) adenocarcinoma (ADC) patients treated with neoadjuvant docetaxel, cisplatin and 5FU (DCF) chemotherapy, curative intent en-bloc resection, and extended lymphadenectomy (D2 or D3).
METHODS: A prospectively entered database of all esophageal and EGJ ADC patients resected at a high volume referral center was reviewed for cases treated with curative intent DCF and en-bloc resection between 9/07-09/13. Follow up included physical exam Q3m x 2 yrs then Q6m, and endoscopy and CT chest/abdo/pelvis performed Q6 m. Loco-regional (biopsy on endoscopy/regional LNs) and non-regional LNs (mediastinal/retroperitoneal/supraclavicular LNs) recurrences were identified and salvage therapy outcomes were analyzed. Standard statistical techniques were used with data presented as median (interquartile range).
RESULTS: Of 365 patients in the database, 86 (85% Male, 63yrs (IQR 56-70)) patients with locally advanced ADC (cT3 93%; cN+ 69%) met inclusion criteria with a median follow-up of 40mo (IQR 20-53). Locoregional failures occurred in 2 patients (2%), 33 (38%) had solid organ and multiple metastasis, and isolated non-regional LN metastasis in 10 (12%) patients as mediastinal (1), supraclavicular (3), mesenteric (1) and retroperitoneal (5) recurrences. One third of these recurrences occurred within the first post-operative year of histologic diagnosis, and the majority (11/12) within the first 2 years with a median time to recurrence of 14mo. Salvage chemoradiation was completed for 8 (67%) patients, chemotherapy for 3 (25%) and surgery in 2 (16%). Of 12 patients, 10 (83%) are still alive. The median follow-up post-recurrence was 33mo (range 5-54mo) excluding patients diagnosed within the last calendar year. One patient (1/12, 8%) has survived more than 4 years after salvage and is in complete remission; four patients (4/12, 33%) survived more than 2 years after salvage of which 3 patients are in complete remission and alive. Three patients (3/12, 25%) incurred disease progression despite salvage with one death. Four patients (4/12, 33%) have recent or ongoing salvage maneuvers (are within 8mo of recurrence) with satisfactory response at the time of analysis.
CONCLUSION: We have demonstrated that in the absence of neoadjuvant chemoradiation, low rates of loco-regional recurrence can be achieved with en-bloc resection and extended lymphadenectomy after neoadjuvant DCF. Furthermore, in a highly selected population, curative intent salvage maneuvers for loco-regional and non-regional LNs can successfully prolong survival and be potentially curative, highlighting the importance of surveillance especially in the first 2 years after diagnosis.
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