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
ARTICLE HIGHLIGHTS
Research background

The prognosis of metastatic oesophageal cancer is poor. The rate of oligometastatic oesophageal cancer is not well established nor is the survival benefit of intervention. As a result, current guidelines advocate against a proactive approach, which is incongruent with other oligometastatic cancers such as colorectal cancer. Based on a policy of active postoperative surveillance and survival outcomes of patients with oligometastatic disease treated with curative intent at our institution, we advocate for more intensive surveillance strategies to identify patients with curative potential early and thus improve long-term survival.

Research motivation

To evaluate the impact of a policy of active surveillance and aggressive management of confirmed metastases on long-term survival.

Research objectives

To examine survival outcomes in patients who underwent active surveillance and targeted therapy of their oligometastatic disease, either at diagnosis or on follow-up surveillance, at our institution. When compared to incomplete clinical responders to neoadjuvant chemoradiotherapy (nCRT) for non-metastatic oesophageal cancer who underwent surgery on their primary tumour, the median overall survival of the oligometastatic cohort was statistically significantly longer. These findings suggest that aggressive treatment of confirmed metastases can be rewarded with impressive survival data and that a more proactive approach to oesophageal oligometastases should be considered.

Research methods

A prospectively maintained database of patients diagnosed with oesophageal carcinoma and treated with curative intent in a single institution 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 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.

Research results

The overall survival of patients with oligometastatic disease who were treated for cure at our institution is impressive and statistically significantly longer than incomplete clinical responders without metastatic disease who subsequently underwent surgery on their primary tumour. These results suggest that intensive follow-up and aggressive management of confirmed metastases may improve long-term survival. Further studies are needed to prospectively identify the rate of oligometastatic recurrence in oesophageal carcinoma and evaluate the cost-benefit ratio of a policy of active surveillance and aggressive management of confirmed oligometastatic disease.

Research conclusions

In view of recent diagnostic and therapeutic advances, intensive follow-up and aggressive treatment of confirmed metastases may improve long-term survival in patients with oligometastatic oesophageal carcinoma.

Research perspectives

Further research should prospectively establish the rate of oligometastatic recurrence in oesophageal carcinoma to evaluate the cost-benefit ratio of active surveillance and aggressive management and inform future clinical guidelines.