Patients with locally advanced esophageal carcinoma nonresponder to radiochemotherapy: Who will benefit from surgery?

Background: In patients who are nonresponders to primary radiochemotherapy (RCT), prognosis is poor, leading mostly to palliation. Salvage surgery may have a survival benefit otherwise complete. Our aim was to identify predictors of R0 resection in these patients. Methods: In 98 nonresponders with locally advanced infracarinal tumors, curative salvage surgery was attempted. Resection was R0 in 62.2% and incomplete in 37.8% of cases. Univariate and multivariate analyses included pre-RCT and post-RCT variables collected prospectively. Results: Overall survival was higher in the R0 resection group (18.4 vs 8.6 months, P < .001). Independent predictors of R0 resection were tumor height <= 5 cm on barium swallow (P = .045) and aortic contact > 90 degrees on computed tomography (P = .039) evaluated after RCT. Three groups of patients were constructed: 1, tumor height <= 5 cm with aortic contact <= 90 degrees (n = 43); 2, tumor height between 6 and 10 cm with aortic contact <= 90 degrees (n = 32); and 3, aortic contact > 90 degrees irrespective of tumor height (n = 23). Rates of R0 resection were 81%, 53%, and 39%, respectively (P = .001). Conclusion: Salvage esophagectomy should be systematically attempted in nonresponders with tumor height <= 5 cm on barium swallow and aortic contact <= 90 degrees on computed tomography and discussed case by case for other patients.