Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 64, Num. 6, 2002, pp. 532-533

Indian Journal of Surgery, Vol. 64, No. 6, Nov - Dec. 2002, pp. 532-533

Case Report

"Salvage" Transhiatal Oesophagectomy After Unsuccessful Curative Chemoradiotherapy for Squamous Cell Cancer of the Oesophagus

Dhananjaya Sharma, Arun Saxena, V. K. Raina

GI Surgery Unit, Department of Surgery, NSCB Government Medical College & Allied Hospitals, Jabalpur, Madhya Pradesh
Address for correspondence: Dr. Dhananjaya Sharma, P-10, Medical College Campus, Jabalpur - 482003, Madhya Pradesh, E-mail: dhanshar@hotmail.com

Paper received: September 2001
Paper accepted: January 2002

Code Number: is02014

Abstract

A patient who underwent a palliative transhiatal oesophagectomy after failed chemoradiation is presented and the issues related to this management option in oesophageal cancer are discussed.

Key words: Cancer oesophagus, Chemoradiation, Oesophagectomy, Transhiatal

CASE REPORT

PK, 36-year-old male diagnosed as an operable squamous cell cancer of the oesophagus of the lower one third refused surgery and chose to undergo curative chemoradiotherapy. He underwent radiation with 45 Gy and a simultaneous therapy of three cycles of Cis-Platin / 5-Fluorouracil over three months. Patient tolerated the chemoradiation well, but showed no response; the dysphagia increased and finally after three months, patient was referred back to the G I Surgery Unit with absolute dysphagia. He was offered palliative oesophagectomy because of his good general health status and as he had no clinical or radiological evidence of major mediastinal extension or distant metastasis. He underwent a transhiatal oesophagectomy, gastric transposition through the oesophageal bed, and cervical oesophago-gastrostomy. The surgery and post-operative recovery were uneventful. Patient was kept under monthly follow-up and remained satisfied with his quality of deglutition and life until16 months of surgery when dysphagia recurred. Investigations revealed gross mediastinal and peritoneal recurrence along with multiple metastases in liver and he eventually succumbed after 17 months of surgery.

DISCUSSION

Surgery is the traditional treatment for operable squamous cell cancer of the oesophagus, while chemoradiotherapy is the standard treatment for non-resectable oesophageal carcinoma. Curative chemoradiotherapy for squamous cell cancer of the oesophagus has the obvious attraction of organ preservation and avoiding the morbidity/ mortality of a major operative procedure like oesophagectomy. A pathological complete response (complete regression with no residual tumour in the resected oesophagus) to chemoradiotherapy has been identified to significantly enhance survival,¹ but factors that would allow prediction of response, so the "responders" can be submitted to chemoradiation, are yet to be identified. Data available on results of "salvage" oesophagectomy after unsuccessful curative chemoradiotherapy for squamous cell cancer of the oesophagus is rather scanty.² This may be due to many factors: poor general condition of patients due to morbidity of full course of chemoradiotherapy, fear of higher postoperative mortality rate and the argument that resection is not necessary after chemoradiotherapy because "complete responders" do not need it and patients with residual disease may not have any survival benefit.³

Proponents of continued surgical exploration after chemoradiation have many points in favor of their philosophy. ^4,5

1. Neither subjective improvement in dysphagia nor objective assessment of the response to chemoradiotherapy correlate with the final pTNM staging.
2. Since tumour may be replaced with fibrosis, and persistent lymphadenopathy may be reactive rather than metastatic disease, it is difficult to evaluate the presence of residual disease after chemoradiotherapy.
3. Careful histopathological assessment of the resected specimen remains the "gold standard" for documenting effectiveness of therapy and only surgical resection, can provide accurate prognostic information and durable and efficient palliation of dysphagia.

In the present case resection was undertaken as the restoration of swallowing function was considered critical for providing good quality of life and this premise was vindicated in this patient. The transhiatal dissection was difficult due to severe fibrosis but was possible under vision as the cancer was in the lower one third. Pleural adhesions and major bleeding from areas of post-chemoradiation fibrosis is an anticipated problem in such cases.

However, it must be emphasized that this high-risk difficult surgery must remain an exceptional indication; but it can be beneficial, in carefully selected patients.

REFERENCES

1. Mandard AM, Dalibard F, Mandard JC, et al. Pathologic assessment of tumor regression after preoperative chemoradiotherapy of esophageal carcinoma. Clinicopathologic correlations. Cancer 1994; 73: 2680-6.
2. Meunier B, Raoul J, Le Prise E, et al. Salvage esophagectomy after unsuccessful curative chemoradiotherapy for squamous cell cancer of the esophagus. Dig Surg 1998; 15: 224-6.
3. de Pree C, Aapro MS, Spiliopoulos A, et al. Combined chemotherapy and radiotherapy, followed or not by surgery, in squamous cell carcinoma of the esophagus. Ann Oncol 1995; 6: 551-7.
4. O'Reilly S, Forastiere AA. Is surgery necessary with multimodality treatment of oesophageal cancer? Ann Oncol. 1995; 6: 519-21.
5. Van Raemdonck D, Van Cutsem E, et al. Induction therapy for clinical T4 oesophageal carcinoma; a plea for continued surgical exploration. Eur J Cardiothorac Surg 1997; 11: 828-37.

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