Observational Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Sep 27, 2022; 14(9): 997-1007
Published online Sep 27, 2022. doi: 10.4240/wjgs.v14.i9.997
Oesophageal cancer metastases: An observational study of a more aggressive approach
Lianne Pickett, Mary Dunne, Orla Monaghan, Liam Grogan, Oscar Breathnach, Thomas N Walsh
Lianne Pickett, Department of Surgery, Connolly Hospital, Blanchardstown, Dublin D15 X40D, Ireland
Mary Dunne, Clinical Trials Resource Unit, St Luke's Radiation Oncology Network, Dublin D06 HH36, Ireland
Orla Monaghan, Department of Radiation Oncology, St Luke's Radiation Oncology Network, Dublin D06 HH36, Ireland
Liam Grogan, Oscar Breathnach, Department of Medical Oncology, Beaumont Hospital, Dublin D09 V2N0, Ireland
Thomas N Walsh, Department of Surgery, RCSI Bahrain, Adliya 15503, Bahrain
Author contributions: Walsh TN was the guarantor, designed the study, participated in the acquisition of data, and revised and edited the article critically; Pickett L acquired, analysed, and interpreted the data and drafted the initial manuscript; Dunne M statistically analysed the data and edited the manuscript; Monaghan O, Grogan L, and Breathnach O reviewed the article and made critical revisions related to important intellectual content.
Institutional review board statement: The study was reviewed and approved by the Connolly Hospital Institutional Review Board.
Informed consent statement: As this was a retrospective audit and many patients were not alive at the commencement of this study, written informed consent was not feasible/obtained. This was an observational study, and no patient received treatment as part of the study. Furthermore, we have not included any identifiable patient information in our manuscript. Verbal consent, although not required, was obtained where appropriate/feasible.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: The statistical analysis and dataset are available from the corresponding author at lianne.pickett@ucdconnect.ie. As this was a retrospective audit consent was not routinely obtained but the presented data are anonymized, and risk of identification is low.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Lianne Pickett, MB, ChB, MCh, Doctor, Department of Surgery, Connolly Hospital, Blanchardstown, Mill Road, Abbots Town, Dublin D15 X40D, Ireland. lianne.pickett@ucdconnect.ie
Received: December 18, 2021
Peer-review started: December 18, 2021
First decision: April 19, 2022
Revised: May 4, 2022
Accepted: August 30, 2022
Article in press: August 30, 2022
Published online: September 27, 2022
Processing time: 277 Days and 22.1 Hours
Abstract
BACKGROUND

The prognosis for oesophageal carcinoma is poor, but once distant metastases emerge the prognosis is considered hopeless. There is no consistent protocol for the early identification and aggressive management of metastases.

AIM

To examine the outcome of a policy of active postoperative surveillance with aggressive treatment of confirmed metastases.

METHODS

A prospectively maintained database of 205 patients diagnosed with oesophageal carcinoma between 1998 and 2019 and treated with curative intent was interrogated for patients with metastases, either at diagnosis or on follow-up surveillance and treated for cure. This cohort was compared with incomplete clinical responders to neoadjuvant chemoradiotherapy (nCRT) who subsequently underwent surgery on their primary tumour. Overall survival was estimated using the Kaplan-Meier method, and the log-rank test was used to compare survival differences between groups.

RESULTS

Of 205 patients, 11 (5.4%) had metastases treated for cure (82% male; median age 60 years; 9 adenocarcinoma and 2 squamous cell carcinomas). All had undergone neoadjuvant chemotherapy or chemoradiotherapy, followed by surgery in all but 1 case. Of the 11 patients, 4 had metastatic disease at diagnosis, of whom 3 were successfully downstaged with nCRT before definitive surgery; 2 of these 4 also developed oligometastatic recurrence and were treated with curative intent. Following definitive treatment, 7 had treatment for metachronous oligometastatic disease; 5 of whom underwent metastasectomy (adrenal × 2; lung × 2; liver × 1). The median overall survival was 10.9 years [95% confidence interval (CI): 0.7-21.0 years], which was statistically significantly longer than incomplete clinical responders undergoing surgery on the primary tumour without metastatic intervention [n = 62; median overall survival = 1.9 (95%CI: 1.1-2.7; P = 0.012]. The cumulative proportion surviving 1, 3, and 5 years was 100%, 91%, and 61%, respectively compared to 71%, 36%, and 25% for incomplete clinical responders undergoing surgery on the primary tumour who did not undergo treatment for metastatic disease.

CONCLUSION

Metastatic oesophageal cancer represents a unique challenge, but aggressive treatment can be rewarded with impressive survival data. In view of recent advances in targeted therapies, intensive follow-up may yield a greater number of patients with curative potential and thus improved long-term survival.

Keywords: Oesophageal metastases; Oligometastases; Active surveillance; Treatment for cure; Metastasectomy; Survival

Core Tip: Modern imaging technologies can detect oligometastatic oesophageal cancer earlier than ever before, and targeted multimodal therapies, combined with innovative surgery, increases the potential for cure. Unfortunately, current guidelines do not reflect these advances and all too often consign patients to palliation. This approach is incongruous with other oligometastatic cancers such as colorectal cancer. Based on the survival outcomes of patients with oligometastatic disease treated for cure at our institution we advocate for more intensive surveillance strategies for earlier identification of patients with curative potential to improve overall long-term survival.