Survival after esophagectomy for metastatic esophageal cancer: should the role of surgery be reconsidered?
Academic Article
Overview
abstract
BACKGROUND: Standard treatment of stage IV esophageal cancer (EC) is systemic therapy, with surgery for the primary tumor considered contraindicated. This study aimed to assess the effect of surgical resection on the outcomes of patients with metastatic EC. METHODS: Our institution's institutional review board-approved database of 1408 esophagectomies (1994-2024) was reviewed, identifying 19 patients with distant disease (stage IV) based on the American Joint Committee on Cancer Staging Manual, eighth Edition, who were found before or at the time of surgical resection. Demographics, clinical characteristics, and survival for metastatic vs nonmetastatic patients were compared using the Fisher exact, Wilcoxon rank-sum, and Kaplan-Meier tests. In addition, metastatic disease subanalysis was performed. RESULTS: Compared with patients with nonstage IV disease, those with stage IV disease were younger (64 vs 57 years, respectively; P =.003) and non-Caucasian (5.7% vs 15.8%, respectively; P <.001). However, most patients in both groups were male (P =.46) and had adenocarcinoma (P =.16). The postoperative complication rates were similar between cohorts (57.9% in patients with stage IV disease vs 63.8% in patients with nonstage IV disease; P =.60). In the stage IV subanalysis, patients who underwent surgery >1 year after stage IV disease diagnosis had better survival than those diagnosed <1 year before or during surgery (P =.04). For patients with stage IV disease diagnosed >1 year before surgery, a shorter overall survival was observed in patients with programmed death-ligand 1 (PD-L1) positivity than in those with PD-L1 negativity (18.7 months vs median OS [mOS] not reached, respectively; P =.94). However, neither the human epidermal growth factor receptor 2 (HER2neu) positive nor HER2neu-negative groups reached mOS (P =.24). CONCLUSION: Esophagectomy for highly selected patients with stage IV EC demonstrates similar postoperative complication rates to surgery for locally advanced EC. For patients with stage IV EC, diagnosis-to-surgery intervals > 12 months demonstrated better outcomes. The role of surgery in treating stage IV EC, preferably >1 year after stage IV diagnosis, warrants further study.
