Monitoring for Recurrence After Esophagectomy

Postoperative Recurrence Pattern of Clinical Stage I Esophageal Cancer After Esophagectomy with Two- or Three-Field Lymph Node Dissection: Supplementary Analysis from JCOG0502

BACKGROUND

Although recurrence after curative surgery for cT1bN0M0 clinical stage I (cStage I) esophageal squamous cell carcinoma (ESCC) is not rare, reports of recurrence analyses are sparse. Detailed data on optimal postoperative follow-up evaluation of cStage I ESCC are lacking. This study aimed to evaluate the frequency, characteristics, and predictors of postoperative recurrence in patients with cT1bN0M0 cStage I ESCC.

METHODS

The study analyzed 210 patients who underwent surgery for cT1bN0M0 cStage I ESCC and a follow-up computed tomography (CT) examination in the prospective multicenter study, JCOG0502. The study categorized the characteristics of postoperative recurrences such as the recurrence sites and whether regional/non-regional lymph nodes (LNs) and single/multiple organs were involved. Backward elimination was applied (p < 0.2) to identify postoperative recurrence predictors and obtained hazard ratios (HRs) based on Fine and Gray's model.

RESULTS

Postoperative recurrence was experienced by 31 patients (14.8%) at one or more of the following sites: regional LNs (n = 18), non-regional LNs (n = 10), lung (n = 2); bone (n = 2), and liver, local recurrence, skin, pleura, pericardium, and other (n = 1 each). In four patients, the first recurrence developed in multiple organs. The median interval between trial registration and the first recurrence was 18.6 months. In multivariable analyses, pathologic nodal metastasis (hazard ratio [HR], 3.29; p = 0.003), tumor location in the upper-thoracic esophagus versus lower-thoracic esophagus (HR, 6.71; p = 0.013), and two-field lymphadenectomy (HR, 4.31; p = 0.001) were independently associated with the development of postoperative recurrence.

CONCLUSION

The main postoperative recurrence sites of cT1bN0M0 ESCC are the LNs, but recurrence in non-regional LNs or distant organs is also quite common, indicating the importance of post-surgery systemic follow-up evaluation.

Surveillance frequency in resected esophageal cancer: Towards personalization of follow-up

INTRODUCTION

In spite of advances in curative management of esophageal cancer, a significant proportion of patients have early recurrence following resection. The role of CT-guided surveillance remains undefined. This study aims to determine if follow-up can be personalised, to allow detection of clinically relevant recurrence, while reducing low-yield surveillance for patients.

METHODS

A retrospective review was conducted encompassing patients undergoing esophagectomy with curative intent from 1st March 2018-31st May 2022. Routine 3-monthly CT scanning was conducted for 2 years, followed by 6-monthly surveillance for 1 year, and annual surveillance to 5 years. Disease characteristics, time to recurrence and time to death were recorded and interrogated to determine their impact on recurrence and personalization of surveillance.

RESULTS

In total, 190 patients underwent surveillance. Seventy-one (37 %) developed recurrence, with most in the first two years. Those who recurred were younger (63 vs 67, p < 0.001), had higher pathologic staging (p < 0.001), higher tumour regression grade (p = 0.005), higher lymph node ratio (p < 0.001) and high-risk histology (p < 0.001). Most recurrences detected were asymptomatic (94 %). A personalised surveillance score was devised. With strict criteria, 12 % of patients could be excluded from surveillance without compromising detection of asymptomatic recurrence. By broadening criteria, a larger portion of patients could avoid imaging, with a small number of asymptomatic recurrences missed. This would require significant balancing of the risk-benefit ratio for individuals.

CONCLUSION

Intensive surveillance post-resection of esophageal cancer will detect most recurrences while asymptomatic, potentially facilitating intervention. In select patients, routine surveillance could be excluded without compromising oncologic or patient outcomes.

Detrimental impact of late-onset pneumonia on long-term prognosis in oesophageal cancer survivors

BACKGROUD

Oesophageal cancer patients are prone to early- and late-onset pneumonia after oesophagectomy. We aimed to investigate the incidence rate and impact on the long-term prognosis of late-onset pneumonia in oesophageal cancer survivors who survived for at least one year after oesophagectomy without cancer recurrence.

METHODS

We retrospectively reviewed 233 patients with thoracic oesophageal cancer who underwent oesophagectomy with gastric conduit reconstruction between September 2009 and June 2019 at a tertiary referral hospital in Japan. Pneumonia that occurred ≥1 year after oesophagectomy was defined as late-onset pneumonia.

RESULTS

Among the 185 oesophageal cancer survivors, 31 (17%) developed late-onset pneumonia. The cumulative incidence rates of late-onset pneumonia 24, 36, and 60 months after oesophagectomy were 6.4%, 10%, and 21%, respectively, whereas pneumonia recurred at 21%, 31%, and 52% within 6, 12, and 24 months, respectively, after the first pneumonia. Chronic obstructive pulmonary disease, postoperative anastomotic leakage, and loss of skeletal muscle mass were independently associated with late-onset pneumonia, and a combination of these factors further increased the risk. Late-onset pneumonia with hospitalisation had the greatest negative impact on the long-term prognosis as non-cancer deaths (HR, 21; p < 0.001), followed by recurrent late-onset pneumonia (HR, 18; p < 0.001).

CONCLUSIONS

Late-onset pneumonia in oesophageal cancer survivors is significantly associated with an increased risk of recurrent infections and non-cancer deaths. Chronic obstructive pulmonary disease and postoperative muscle loss are risk factors for late-onset pneumonia, and more intensive pharmacological and nutritional interventions should be considered to improve long-term prognosis after oesophagectomy.