Salvage esophagectomy: ``We made too many wrong mistakes''


COMMENTARY
Salvage esophagectomy: ‘‘We made too many wrong mistakes’’
Thomas W. Rice, MD,a,b and Eugene H. Blackstone, MDa,c
Is salvage esophagectomy the solution to failure of
definitive chemoradiotherapy for esophageal cancer? Is
the addition of a more extensive lymphadenectomy to
salvage esophagectomy a therapeutic step forward or a
further compounding of a therapeutic oversight? In
considering the report by Wang and colleagues,1 we are
reminded of Yogi Berra’s explanation for his team’s failure:
‘‘We made too many wrong mistakes.’’

Wang and colleagues1 reported a 14-year experience of
salvage esophagectomy in 140 patients. Despite salvage
surgery in all, 25% were excluded from the analysis. An
additional problem in understanding the applicability of
this experience is that the denominator for the entire
experience with definitive chemotherapy for squamous
cell esophageal cancer was unstated. In this highly select
group of patients, not surprisingly, the ability to resect
(R0) an early yp-stage cancer (ypN0M0) has been
associated with improved survival.2 As previously reported,
tumor biology, reflected by the response to chemo-
radiotherapy (resection of recurrent cancer and not
persistent cancer), was associated with improved survival.2

After a vigorous multistep analysis that failed to
demonstrate a cutoff for optimal lymphadenectomy
(number of nodes excised), Wang and colleagues1

arbitrarily chose to dichotomize this continuous variable.
In the ensuing multivariable analysis, this ‘‘forced’’variable
(�15 resected nodes resected) was associated with
improved survival. However, was this not using statistical
From the Department of Surgery,
a
Cleveland Clinic Lerner College of Medicine,

Cleveland, Ohio; Department of Patient Experience,
b
Cleveland Clinic, Cleveland,

Ohio; and Clinical Investigations,
c
Heart and Vascular Institute, Cleveland Clinic,

Cleveland, Ohio.

Disclosures: Authors have nothing to disclose with regard to commercial support.

Received for publication Jan 20, 2014; accepted for publication Jan 31, 2014;

available ahead of print March 7, 2014.

Address for reprints: Thomas W. Rice, MD, Department of Patient Experience, 9500

Euclid Ave, Desk P29, Cleveland, OH 44195 (E-mail: ricet@ccf.org).

J Thorac Cardiovasc Surg 2014;147:1812

0022-5223/$36.00

Copyright � 2014 by The American Association for Thoracic Surgery
http://dx.doi.org/10.1016/j.jtcvs.2014.01.048

1812 The Journal of Thoracic and Cardiovascular Sur
manipulations until the desired answer had been obtained?
Possibly, the relationship is nonlinear. Lymphadenectomy
was the focus of their report; however, this potentially
spurious finding does not answer the questions concerning
salvage esophagectomy.

It is not unexpected from previous publications that an
adequate R0 resection of a ‘‘recurrent’’ early yp-stage
cancer has the potential for cure.2 However, this clinical
scenario represents a highly selected and uncommon patient
after definitive chemoradiotherapy. Salvage esophagec-
tomy and extended lymphadenectomy is not the answer:
treatment planning in a multidisciplinary setting is. No
extent of lymphadenectomy will remedy the lack of
communication during the prescribing of therapy. Salvage
esophagectomy is a marker of a serious failure of the
medical system.

Failing to prepare, you are preparing to fail.
—Benjamin Franklin
References
1. Wang S, Tachimori Y, Hokamura N, Igaki H, Nakazato H, Kishino T. Prognostic

analysis of salvage esophagectomy following definitive chemoradiotherapy for

esophageal squamous cell carcinoma: the importance of lymphadenectomy.

J Thorac Cardiovasc Surg. February 9, 2014 [Epub ahead of print].

2. Rice TW. Esophageal nightmare: cancer recurrence after definitive chemo-

radiation. Is salvage esophagectomy possible? Semin Thorac Cardiovasc Surg.

2013;25:83-6.
gery c June 2014

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http://refhub.elsevier.com/S0022-5223(14)00178-0/sref1
http://refhub.elsevier.com/S0022-5223(14)00178-0/sref1
http://refhub.elsevier.com/S0022-5223(14)00178-0/sref1
http://refhub.elsevier.com/S0022-5223(14)00178-0/sref1
http://refhub.elsevier.com/S0022-5223(14)00178-0/sref2
http://refhub.elsevier.com/S0022-5223(14)00178-0/sref2
http://refhub.elsevier.com/S0022-5223(14)00178-0/sref2
mailto:ricet@ccf.org
http://dx.doi.org/10.1016/j.jtcvs.2014.01.048

	Salvage esophagectomy: “We made too many wrong mistakes”
	References