Original Article

Esophageal Cancer Recurrence Patterns and Implications

for Surveillance
Feiran Lou, MD, MS, Camelia S. Sima, MD, MS, Prasad S. Adusumilli, MD, Manjit S. Bains, MD,
Inderpal S. Sarkaria, MD, Valerie W. Rusch, MD, and Nabil P. Rizk, MD, MS

Introduction: After definitive treatment of esophageal cancer, with this malignancy will eventually die of the disease.1 Even
patients are at high risk for recurrence. Consistent follow-up is after treatment with curative intent, recurrence often devel-
important for detection and treatment of recurrence. The optimal ops in patients. Regular follow-up after definitive treatment is
surveillance regimen remains undefined. We investigated posttreat- believed to be an important component of cancer care, poten-
ment recurrence patterns and methods of detection in survivors of tially allowing for earlier detection and better management of
esophageal cancer. recurrences. Scant evidence exists on the optimal follow-up
Methods: We retrospectively studied a cohort of patients who had regimen and its impact. As a result, guidelines differ on the
undergone surgical resection for esophageal cancer at our institution method and interval of follow-up for posttreatment surveil-
between 1996 and 2010. Routine computed tomography scan and lance.2,3 The use of computed tomography (CT) scan, positron
upper endoscopy were performed for surveillance. emission tomography (PET)/CT scan, upper endoscopy, and
Results: In total, 1147 patients with resected esophageal adenocarci- serum carcinoembryonic antigen levels for surveillance have
noma or squamous cell carcinoma were included (median follow-up, all been reported.4,5 Although endoscopic ultrasound has been
46 months). Of these, 723 patients (63%) had received neoadjuvant shown to be more sensitive than endoscopy alone for detection
therapy before surgery. During follow-up, there were 595 deaths of locoregional recurrences, it has not been widely used for
(52%) and 435 recurrences (38%) (distant [55%], locoregional surveillance of asymptomatic patients.6–8 The efficacy of each
[28%], or both [17%]). Half of recurrences were detected as a result of surveillance modality has not been systematically assessed in
symptoms (n = 217), 45% by routine chest and abdominal computed large cohorts. Likewise, although there is no consensus on the
tomography scan (n = 194), and 1% by surveillance upper endoscopy optimal frequency of follow-up, several series have demon-
(n = 6). The recurrence rate decreased from 27 per 100 person-years strated that most recurrences occur in the first 2 years after
in posttreatment year 1 to 4 per 100 person-years in year 6. In the first completion of treatment.4,5 The purpose of this study was to
2 years, the rate of recurrence was higher among patients who had evaluate (1) the incidence of esophageal cancer recurrence,
received neoadjuvant therapy (35 per 100 person-years) than among over time, after treatment with curative intent; (2) the means
those who had not (14 per 100 person-years) (p < 0.001). of detection of recurrence; and (3) the outcomes after recur-
Conclusions: The incidence of recurrence is high after esophagec- rence. The ultimate goal was to provide data to support a
tomy for cancer. Surveillance endoscopy has limited value for detec- rational follow-up regimen for surveillance of patients after
tion of asymptomatic local recurrence. The yield from follow-up treatment of esophageal cancer with curative intent.
scans diminishes significantly after the sixth year; surveillance scans
after that point are likely unnecessary. PATIENTS AND METHODS
Key Words: Esophageal cancer, Surveillance, Endoscopy. We conducted a single-institution, retrospective cohort
study in which we reviewed patients who had undergone
(J Thorac Oncol. 2013;8: 1558–1562) esophagectomy for pathologic stage I to III esophageal ade-
nocarcinoma or squamous cell carcinoma at Memorial Sloan-
Kettering Cancer Center (MSKCC) between 1996 and 2010.

E sophageal cancer is the seventh leading cause of cancer

death in men in the United States. Nearly 90% of patients
Staging was performed using the 7th edition of the American
Joint Committee on Cancer Cancer Staging Manual.9 We
extracted baseline information from a prospectively main-
tained database, including demographic variables, pathologic
Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer details, preoperative staging and treatment details, and post-
Center, New York, New York.
Disclosure: The authors declare no conflict of interest. operative disease status and vital status. Of note, at MSKCC,
Financial support: NIH/NCI Cancer Center Support Grant P30 CA008748. it is our practice to use preoperative chemoradiation therapy
Address for correspondence: Nabil P. Rizk, MD, MS, Thoracic Service, in patients with clinical evidence of locoregional advanced
Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 disease (clinical stages II and III). Details on recurrences
York Avenue, New York, NY 10021. E-mail: [email protected]
Copyright © 2013 by the International Association for the Study of Lung
were obtained from medical records from MSKCC and
Cancer outside institutions, when available, and from documented
ISSN: 1556-0864/13/0812-1558 patient communications. In some instances, questionnaires

1558 Journal of Thoracic Oncology  ® • Volume 8, Number 12, December 2013

Journal of Thoracic Oncology  ® • Volume 8, Number 12, December 2013Cancer Recurrence Patterns and Implications for Surveillance

regarding recurrences and long-term complications were RESULTS

mailed every 2 to 3 years to patients who were not receiving Of the 1373 patients who underwent esophagectomy at
follow-up at MSKCC. Recurrence status was censored on the our institution between 1996 and 2010, 1147 were included
date of the last MSKCC clinic visit or outside communication. in the study. Exclusion criteria were histologic type other
Vital status was confirmed using the Social Security Death than squamous cell carcinoma or adenocarcinoma (n = 36),
Index. The study was approved by the MSKCC Institutional Barrett’s esophagus or carcinoma in situ (n = 64), R2 resection
Review Board. (n = 95), stage IV disease (n = 25), primary resection not per-
formed at MSKCC (n = 4), and nonesophageal primary cancer
Definition of Recurrence (n = 2). Follow-up was performed through February 2012. The
After surgery, patients received regular follow-up from median follow-up for those alive and without recurrence at
their surgeon and/or medical oncologist. Clinic visits took study end was 46 months (range, 0–192 months). Table 1 sum-
place every 4 to 6 months for the first 2 years after surgery marizes patient and disease characteristics. Adenocarcinoma
and then yearly thereafter. Each visit consisted of a medical was the predominant histologic type (n = 942 [82%]). A
history, physical examination, and chest and abdominal CT total of 723 patients (63%) had received neoadjuvant therapy
scan. In general, surveillance upper endoscopy was performed before surgery. Combined chemoradiation therapy was more
every 6 months for 2 years and then yearly thereafter by either common than chemotherapy alone. Only 7% of the patients
the primary surgeon or a gastroenterologist. Once a recur- (n = 77) had R1 resection. At the time of review, 435 patients
rence was suspected, patients underwent further workup that (38%) had developed a recurrence and 595 patients (52%)
included PET/CT scan, endoscopic ultrasound, upper endos- had died (Figure 1). Of the 435 patients with evidence of
copy, biopsy, or other modalities specific to the suspected site recurrence, 241 (55%) had distant recurrence, 121 (28%) had
of recurrence. The date of detection of recurrence was defined locoregional recurrence, and 73 (17%) had both types.
as the date at which the initial abnormal surveillance study or
symptomatic presentation led to further workup and diagno-
sis of recurrence. Diagnosis of recurrence was adjudicated by TABLE 1. Patient and Disease Characteristics (n = 1147)
pathologic confirmation or by findings by other study modali- Characteristic n (%)a
ties that led to changes in treatment. Locoregional recurrence
was defined as a recurrence isolated to the area of the anasto- Sex
mosis (perianastomotic) or in lymph nodes in the mediasti- Male 888 (77.4)
num and upper abdomen (supraceliac). Distant recurrence was Female 259 (22.6)
defined as any spread of disease beyond a locoregional recur- Age (yr)
rence. Most patients with confirmed recurrences received che- Mean (SD) 63 (10.7)
motherapy; some received radiation therapy, when possible. Range 21–89
Occasionally, patients received both. In patients who devel- Histologic type
oped an isolated anastomotic recurrence and could tolerate Squamous cell carcinoma 205 (17.9)
further operation, surgical resection was performed. Adenocarcinoma 942 (82.1)
Induction therapy
Statistics Chemotherapy 67 (5.8)
Summary statistics are presented as prevalence, mean Chemoradiation therapy 656 (57.2)
± SD, and median. The average hazard rate of recurrence None 424 (37.0)
for each year after surgery was calculated at 12-month Margins
intervals, as number of recurrences per person-years of fol- R0 1070 (93.3)
low-up during that interval. Time to recurrence and overall R1 77 (6.7)
survival were estimated using the Kaplan–Meier method. Pathologic stage
Patients were followed up from the date of surgery until
0 154 (13.4)
documented recurrence (for time to recurrence analysis) or
IA 194 (16.9)
death (for overall survival analysis). Patients who did not
IB 172 (15.0)
experience the corresponding event during the study period
were censored at the time of the last available follow-up. In IIA 79 (6.9)
addition, in the group of patients who experienced recur- IIB 264 (23.0)
rence, we estimated postrecurrence survival. The log-rank IIIA 140 (12.2)
test was used for univariate comparison between groups. IIIB 71 (6.2)
Multivariate analysis for postrecurrence survival was per- IIIC 73 (6.4)
formed using Cox proportional hazards regression, inves- Recurrence 435 (37.9)
tigating the effect of recurrence type (locoregional versus Distant 241 (55.4)
distant, early versus late), controlling for age, disease stage, Locoregional 121 (27.8)
and neoadjuvant therapy use. The α value was set at 0.05. Distant + locoregional 73 (16.8)
SAS version 9.3 (SAS Institute, Cary, NC) was used to per- a
Percentage of all recurrences.
form all statistical analyses.

Copyright © 2013 by the International Association for the Study of Lung Cancer 1559
Lou et al. Journal of Thoracic Oncology  ® • Volume 8, Number 12, December 2013

TABLE 3. Method of Detection and Upper Endoscopy in

Patients with Perianastomotic Recurrence (n = 40)
Method of Detection/Upper n (%)
Endoscopy
Method of detection
Clinical (symptoms) 26 (65.0)
Computed tomography 5 (12.5)
Upper endoscopy 6 (15.0)
Unknown 2 (5.0)
Chest radiograph 1 (2.5)
Upper endoscopy <3 mo after diagnosis of recurrence
Yes 37 (92.5)
No 3 (7.5)
Upper endoscopy findings (diagnostic or surveillance)
Normal 5 (13.5)
FIGURE 1. Time to recurrence in all patients. Abnormal 32 (86.5)

Detection of Recurrence the diagnosis of recurrence, either for screening or for further
For half of the patients (50%), suspicious symptoms evaluation of possible recurrence; only 46 of these endoscopies
(weight loss, dysphagia, shortness of breath, and neurologic (21%) detected any evidence of malignancy. Of the 40 patients
symptoms) or abnormal physical examinations (cervical or who developed a perianastomotic recurrence, six patients
supraclavicular adenopathy) ultimately led to the diagnosis (15%) had their recurrence initially detected by surveillance
of recurrence (Table 2). Surveillance chest and abdominal upper endoscopy, whereas most patients (n = 26 [65%]) pre-
CT scans detected 45% of recurrences. Among asymptom- sented with symptoms first (Table 3). Of the six patients whose
atic patients, only six cases of recurrence (1%) were detected perianastomotic recurrence was detected by upper endoscopy,
by surveillance upper endoscopy. Interestingly, the type of one underwent a second resection with colon interposition, one
recurrence (distant versus locoregional) did not correlate with received chemoradiation therapy, two underwent chemother-
clinical or subclinical detection (50% versus 56% detected apy alone, and two did not receive further treatment.
clinically in distant and locoregional recurrences, respec-
tively; p = 0.24). During 6 years of follow-up, the pattern of Time to Recurrence
detection of recurrences remained unchanged (p = 0.85). In total, 75% of all recurrences occurred in the first
2 years after surgery; this proportion was lower (63%) for
Upper Endoscopy Surveillance patients who had not received neoadjuvant therapy than for
Because upper endoscopy surveillance may have been those who had (83%) (p < 0.001). The median time to recur-
performed and recorded less reliably at outside centers, we rence was 5.5 years (95% confidence interval [CI], 3.8–8.1
limited our examination of its efficacy to the periods of con- years). The overall recurrence rate was 27 per 100 person-
tinuous follow-up at MSKCC. During follow-up at MSKCC years in postoperative year 1 (95% CI, 23–31 per 100 person-
(median, 31 months; range, 0–192 months), 367 recurrences years) and then rapidly decreased to 4 per 100 person-years
were diagnosed, and only six (2%) were initially detected by by postoperative year 6 (95% CI, 2–8 per 100 person-years)
surveillance upper endoscopy. More than half of the patients (Figure 2). A similar pattern was observed when the analysis
(n = 215 [59%]) with a documented recurrence underwent was limited to patients who had received neoadjuvant therapy.
at least one endoscopy within 3 months (before or after) of In this latter group of patients, however, recurrence occurred
at a higher initial rate (35 per 100 person-years in postopera-
TABLE 2. Method of Detection in All Patients with a tive year 1; 95% CI, 30–40 per 100 person-years) (Figure 3).
Recurrence (n = 435) In contrast, patients who had not received neoadjuvant ther-
apy developed recurrences at a lower initial rate (14 per 100
Method of Detection n (%) person-years; 95% CI, 10–19 per 100 person-years) but then
Clinical (symptoms)a 217 (49.9) experienced a slower rate of decline over time.
Computed tomography 194 (44.6)
Upper endoscopy 6 (1.4) Survival
Otherb 2 (0.5) Supplementary Figure 1 (Supplementary Digital Content
Unknown 16 (3.7) 1, http://links.lww.com/JTO/A474) and Supplementary Figure
a
Clinical detection includes symptoms and/or abnormal physical examinations.
2 (Supplementary Digital Content 2, http://links.lww.com/JTO/
b
Other detection methods include tests not routinely performed at Memorial A475) show overall survival following surgery among patients
Sloan-Kettering Cancer Center: positron emission tomography/computed tomography, who had and had not received neoadjuvant therapy, strati-
carcinoembryonic antigen level, chest radiograph, and magnetic resonance imaging.
fied by nodal stage and pathologic stage, respectively. Median

1560 Copyright © 2013 by the International Association for the Study of Lung Cancer
Journal of Thoracic Oncology  ® • Volume 8, Number 12, December 2013Cancer Recurrence Patterns and Implications for Surveillance

Surveillance modalities, such as CT scans, laboratory tests, and

upper endoscopies, are recommended only as clinically indi-
cated. Many institutions (including ours), however, perform rou-
tine imaging and endoscopic examinations for surveillance of
asymptomatic patients.2,4 The assumed value of a surveillance
program is that the detection of recurrences at an earlier time
might result in improved survival and quality of life. The ben-
efits of intensive surveillance, however, must be weighed against
costs and potential side effects. At present, there is no consensus
on the optimal follow-up regimen after esophagectomy for can-
cer. The aim of this study was to evaluate recurrence patterns
after esophagectomy for cancer and, on the basis of these find-
ings, to propose a rational follow-up surveillance program.

Methods of Detection
Half of the patients (50%) who developed a recurrence
initially presented with symptoms, even while undergoing
FIGURE 2. Average hazard rate of recurrence in all patients. routine surveillance imaging; 45% of patients who devel-
oped a recurrence were diagnosed by surveillance CT scan.
postrecurrence survival among the 237 patients who experi- This pattern of detection of recurrences remained the same
enced recurrence was 11 months (Supplementary Figure 3, throughout the follow-up period. Furthermore, recurrences
Supplementary Digital Content 3, http://links.lww.com/JTO/ detected clinically were associated with significantly worse
A476). Patients whose recurrence was initially detected by radio- survival, compared with recurrences detected subclinically,
graphic or laboratory tests had longer survival after diagnosis through surveillance screening. Because all patients under-
of recurrence than those who presented with symptoms and went a similar follow-up regimen and therefore had the same
received clinical diagnosis (p = 0.01) (Supplementary Figure chance for early detection by surveillance, the association
4, Supplementary Digital Content 4, http://links.lww.com/JTO/ between method of diagnosis and survival is likely attribut-
A501). Likewise, the site of the first recurrence and the time to able to a more aggressive tumor biology in patients diagnosed
diagnosis of recurrence were associated with postrecurrence sur- clinically, rather than to any benefit of “earlier” detection by
vival. Those with only locoregional disease (n = 121) (p < 0.001) surveillance screening. Nonetheless, our experience with rou-
and those whose recurrence was detected more than 2 years after tine CT scan points to its important role in the detection of
surgery (n = 99) (p = 0.003) had longer survival, even after age, recurrences before clinical presentation of symptoms. Our
disease stage, and neoadjuvant therapy status were controlled for. results differ from those of Abate et al.5 In their retrospective
series on follow-up after treatment of esophageal adenocarci-
noma, only 17% of recurrences were diagnosed as a result of
DISCUSSION symptomatic presentation; 60% and 18% of recurrences were
Esophageal cancer is an aggressive malignancy with high diagnosed by routine CT and PET scan, respectively. The dif-
rates of recurrence, even after completion of therapy with cura- ference in detection of recurrences between their study and
tive intent. Current National Comprehensive Cancer Network ours may be attributable to several factors: the retrospective
guidelines2 recommend more-frequent follow-up, with medi- nature of both studies, the differences in follow-up protocols,
cal history and physical examination, during the first 5 years. and the definitions of “symptomatic recurrence” used. In con-
trast to the surveillance regimen in our study, their surveil-
lance regimen included more-frequent follow-up and routine
PET/CT scans in some patients. Despite the differences in
results, both series demonstrate that intensive follow-up with
routine imaging effectively identifies subclinical recurrences.
Unlike CT scans, surveillance upper endoscopies rarely
detected asymptomatic recurrences. Although there has been
no published evidence on the efficacy of surveillance upper
endoscopies, our follow-up regimen has included this modal-
ity because of its presumed ability to detect locoregional recur-
rences. Furthermore, perianastomotic disease recurrences are
conceivably amenable to a second curative resection in select
patients.10 Although upper endoscopy confirmed perianasto-
motic recurrence (when present) in the majority of patients
(80%), the initiating event (i.e., symptom) that prompted the
FIGURE 3. Recurrence rates in patient with and without endoscopy was typically dysphagia (65%), rather than detec-
neoadjuvant therapy. tion by any surveillance modality. In asymptomatic patients

Copyright © 2013 by the International Association for the Study of Lung Cancer 1561
Lou et al. Journal of Thoracic Oncology  ® • Volume 8, Number 12, December 2013

with perianastomotic recurrences, upper endoscopy rarely and locoregional disease did the worst. This finding likely rep-
detected relapse (15%), which is likely attributable to the resents the overall tumor burden at the time of detection.
fact that this recurrence pattern often represents extraluminal
nodal disease without endoluminal extension. Nevertheless, Limitations
most patients with perianastomotic recurrences first presented Several limitations in our study should be noted. The
with symptoms. Furthermore, only one of six patients whose details on recurrences were retrospectively obtained and
recurrence was detected by surveillance endoscopy ultimately are therefore subject to significant bias. As this is a single-
underwent further surgery with curative intent. Given the cost institution experience, our results may have limited general-
and invasiveness of this modality, surveillance upper endos- izability to other practices. Most importantly, this study was
copy seems to be of limited use for the follow-up of patients not designed to evaluate the effect of intensive follow-up on
after curative treatment of esophageal cancer. survival or patient-oriented outcomes. Although routine CT
scans detected subclinical recurrences, prospective studies
Timing of Recurrence are needed to assess the effects of early diagnosis on survival,
A rational follow-up regimen for surveillance of patients treatment outcomes, and quality of life.
after esophagectomy for cancer should correspond to the like-
lihood of recurrence in the patients at risk (i.e., the recurrence CONCLUSION
rate), rather than the absolute number of patients experienc- Surveillance upper endoscopy rarely detected subclinical
ing recurrence. Our current screening regimen includes more- recurrences in survivors of esophageal cancer. Considering the
intense follow-up in the first 2 years—reflecting the belief costs and potential complications of the procedure, we do not rec-
that most recurrences occur during that period—followed by ommend its routine use for follow-up of asymptomatic patients
yearly CT scans thereafter, for an indefinite period. Indeed, we after surgical resection. CT scans of the chest and abdomen, on the
found that, overall, 54% and 21% of recurrences were diag- other hand, were effective at identifying subclinical recurrences.
nosed in the first and second years after surgery, respectively; For patients who have undergone preoperative treatment of clini-
these findings are similar to those described by Mariette et al.4 cally advanced disease (clinical stage II or III), follow-up should
The recurrence rate was highest in postoperative year 1 (27 be more frequent during the first 2 years (i.e., every 4–6 months),
per 100 person-years). This rate then dropped quickly in year 2 followed by yearly screening thereafter. For patients with earlier
(17 per 100 person-years), after which it declined more slowly clinical stage disease, follow-up should be most frequent during
to 4 per 100 person-years by year 6. When the same analysis the first year, followed by yearly CT scans afterward. As the yield
was performed on patients on the basis of whether they had from follow-up scans diminishes significantly after the sixth year,
received neoadjuvant therapy, we found that patients who had surveillance scans after that point are likely unnecessary.
received neoadjuvant therapy had a very high initial rate of
recurrence, followed by a sharp drop in the second year and
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1562 Copyright © 2013 by the International Association for the Study of Lung Cancer