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ecurrence after Esophagectomy fordenocarcinoma: Defining Optimal Follow-Up

ntervals and Testingmmanuele Abate, MD, Steven R DeMeester, MD, FACS, Joerg Zehetner, MD, Arzu Oezcelik, MD,hahin Ayazi, MD, Jesse Costales, MS, Farzaneh Banki, MD, John C Lipham, MD, FACS,effrey A Hagen, MD, FACS, Tom R DeMeester, MD, FACS

BACKGROUND: To determine the optimal follow-up strategy after esophagectomy for adenocarcinoma of theesophagus or gastroesophageal junction by evaluating the timing of recurrence and the methodthat first detected the recurrence.

STUDY DESIGN: Between 1991 and 2007, 590 patients had an esophagectomy for adenocarcinoma. Recur-rence occurred in 233 (40%) and, of those, 174 had complete follow-up at our center witha protocol that consisted of an office visit with CT scans and laboratory studies every 3months for 3 years, every 6 months for 2 years, and then annually. A subset of patients hadPET annually.

RESULTS: Recurrence in the 174 patients with complete follow-up was systemic in 104 (60%),locoregional/nodal in 51 (30%), and both in 19 (10%). Recurrence was first suspected bysymptoms and/or physical examination in 29 patients (17%), by CT scan in 105 (60%), PETin 32 (18%), and by elevated CEA in 8 (5%). Recurrence was detected at a median of 11 months(range 3 to 72 months) and occurred later after esophagectomy alone compared with patientswho received neoadjuvant therapy (12 versus 8 months; p � 0.01), but the pattern of recurrencewas similar. More than 90% of recurrences were detected within 2 years after neoadjuvanttherapy, compared with 3 years after esophagectomy alone. Median survival after recurrence was7 months and was significantly longer in patients treated for the recurrence (9 versus 3 months;p � 0.001).

CONCLUSIONS: Frequent early follow-up is appropriate after esophagectomy for adenocarcinoma because�90% of recurrences will occur by 3 years after esophagectomy alone and by 2 years followingneoadjuvant therapy. Beyond these time periods, 2% to 3% of recurrences were detected eachyear, suggesting that annual follow-up is adequate. Survival after recurrence was improved withtherapy, confirming the use of careful follow-up in these patients. ( J Am Coll Surg 2010;210:

428–435. © 2010 by the American College of Surgeons)

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sophageal cancer is the 6th leading cause of death from can-er worldwide and the 7th among American men.1,2 Adeno-arcinoma is the most common type of esophageal cancer inhe Western world and the prevalence is increasing faster than

isclosure Information: Nothing to disclose.resented at the American College of Surgeons 95th Annual Clinical Con-ress, Chicago, IL, October 2009.

eceived October 17, 2009; Revised January 5, 2010; Accepted January 6,010.rom the Division of Thoracic Surgery, Department of Surgery, Keck Schoolf Medicine, University of Southern California, Los Angeles, CA.orrespondence address: Steven R DeMeester, MD, Department of Surgery,eck School of Medicine, University of Southern California, 1510 San Pablot, HCC 1, Suite 514, Los Angeles, CA 90033. email: sdemeester@

eurgery.usc.edu

4282010 by the American College of Surgeons

ublished by Elsevier Inc.

ny other cancer.3 Esophagectomy remains the mainstay ofherapy, but cancer recurrence is common because of the ad-anced stage of disease at presentation in many patients.

Follow-up protocols after esophagectomy vary widelyround the world and reflect institutional preferences be-ause there is scant published data indicating appropriatentervals and studies. Commonly, CT scans are used tovaluate for recurrent or metastatic disease, but they arexpensive and associated with substantial radiation expo-ure for the patient. PET scans have become increasinglyopular, but these also are expensive and of unprovenalue. The aim of this study was to evaluate the timing andattern of recurrence of adenocarcinoma to determine theppropriate intervals and methods of follow-up after

sophagectomy.

ISSN 1072-7515/10/$36.00doi:10.1016/j.jamcollsurg.2010.01.006

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429Vol. 210, No. 4, April 2010 Abate et al Recurrence after Esophagectomy for Adenocarcinoma

ETHODSe performed a retrospective review of the charts of all

atients who had an esophagectomy for adenocarcinomaetween 1991 and 2007. All patients with recurrence aftersophagectomy were identified, and those who had consis-ent follow-up at our center were selected for this study.atients who chose to follow-up at another location andhose with incomplete follow-up at our center were ex-luded. In addition, patients were excluded from the studyf they were found to have systemic metastatic disease pre-peratively or intraoperatively, or if they had an incompleteesection (R1) on final pathology. This study was approvedy the Institutional Review Board of the University ofouthern California.

Assessment of the extent of the disease before surgicalntervention included upper endoscopy with biopsy, ahest and abdominal CT scan, and, when they becamevailable, endoscopic ultrasound, PET, or fusion CT-PETcan.The surgical techniques performed were transthoracicn bloc, transhiatal, vagal-sparing, or minimally invasivehoracoscopic/laparoscopic esophagectomy. Most patientsere reconstructed with a gastric pull-up. Patients with

ocoregional advanced tumors received neoadjuvant ther-py (chemo- or chemoradiotherapy) at the discretion of thettending surgeon and oncologist. Adjuvant chemotherapyas recommended for patients with multiple involved

ymph nodes on final pathology.Patients were followed by the operating surgeon at de-

ined intervals: every 3 months for the first 3 years, everymonths for the next 2 years, and yearly thereafter.

ollow-up consisted of history and physical examination,omplete blood count, serum chemistry tests, CEA level,nd contrast-enhanced CT scan of the chest and abdomen.ET scans were obtained yearly by some of the surgeons.Locoregional recurrence was defined as tumor occurring

t the anastomotic site or in the lymph nodes in the neck,ediastinum, or upper abdomen. Systemic recurrence was

efined as hematogenous metastases to the brain, bone, orisceral organs, or peritoneal carcinomatosis. Combinedecurrence was defined as the presence of both locoregionalnd systemic recurrence. Suspected recurrence was con-

able 1. Characteristics of the Study PopulationPrimary operation (n �

ender, female/male 23/104ge, y, median (range) 69 (59�75)eoadjuvant therapy, nChemotherapy only, n (%)Chemoradiotherapy, n (%) —

ollow-up time, mo, median (range) 20 (10�34)

irmed with histology whenever possible. Some patients c

ere treated empirically based on CT or PET scan evidencef multifocal recurrence. Once recurrence was confirmed,he majority of patients underwent treatment with chemo-herapy, radiotherapy, or both. In patients with resectable,imited disease, surgical resection with or without adjuvanthemotherapy or chemoradiotherapy was the preferredpproach.

tatistical analysisummary statistics were expressed as median with inter-uartile range (IQR). Chi-square test was used for categor-cal variables and the Mann-Whitney test or Kruskal-Wallisest were used for continuous variables. Survival was calcu-ated using the method of Kaplan-Meier and comparedith log-rank test. A p value �0.05 was considered

ignificant.

ESULTSf 590 patients who had an esophagectomy for adeno-

arcinoma between 1991 and 2007, recurrence wasdentified in 233 patients (40%). From these 233 pa-ients, there were 174 who had consistent follow-up atur center according to the described protocol. Neoad-uvant therapy was used in 47 patients, and 127 hadrimary surgical resection (Table 1). Median duration ofollow-up was 18 months (IQR 10 to 33), and was notignificantly different between patients who had neoadju-ant therapy or primary resection (p � 0.1).

etection of recurrenceecurrence was first suspected by symptoms and/or phys-

cal examination in 29 patients (17%), by CT scan in 10560%), PET in 32 (18%), and by elevated CEA in 8 (5%).ysphagia was the most common symptom associatedith recurrence (46%), followed by bone pain (17%),owel obstruction (13%), neurological deficits (8%), an-rexia with weight loss (8%), and others (8%). The mostommon physical finding associated with recurrence wasnlarged cervical nodes (60%). Identification of recurrenceiffered between CT and PET scans. By CT scan the most

) Neoadjuvant � esophagectomy (n � 47) p Value

5/42 0.256 (50�66) 0.01

4722 (47)25 (53) —12 (9�26) 0.1

127

ommon site for suspected recurrence was the liver (36%),

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430 Abate et al Recurrence after Esophagectomy for Adenocarcinoma J Am Coll Surg

ollowed by thoracoabdominal lymph nodes (31%), lung18%), adrenal glands (5%), cervical nodes (4%), bone3%), spleen (1%), and others (2%). By PET scan, theost common site for suspected recurrence was in thora-

oabdominal lymph nodes (25%), followed by the liver19%), lung (19%), cervical lymph nodes (16%), bone9%), and others (12%). Recurrent disease based on CTnd/or PET scan was isolated to a single site or organ in 22atients and was multifocal in 152 patients. In the 8 pa-ients suspected of having recurrence based on an elevatedEA value, the median increase from the prior (baseline)EA value was 51 (IQR 12 to 78).Overall, recurrence was detected at a median of 11onths post-resection (IQR 6 to 19), but the interval to

ecurrence was shorter in patients who had received neod-uvant therapy (neoadjuvant therapy � 8 months versusrimary surgery � 12 months; p � 0.01). More than 90%f recurrences were detected within 21 months of resectionn patients who had received neoadjuvant therapy com-ared with 33 months for the primary surgery groupFig. 1). The percentage of recurrences detected during each-month interval of follow-up is shown in Figure 2. Theighest percentage of recurrences (22%) occurred withinhe first 3 months after esophagectomy in patients who hadeoadjuvant therapy and between 6 and 9 months in therimary surgery group (17%). Beyond the 3rd year ofollow-up, only 2% to 3% of recurrences were detectednnually. In this series, the longest interval to recurrence in

Figure 1. Recurrence over time after esophagectthose who had neoadjuvant therapy followed by esfor both groups are indicated.

atients who had neoadjuvant therapy was 39 months, t

ompared with 72 months after primary resection. Thereas no difference in the type of recurrence between patientsho had neoadjuvant therapy or primary surgical resection

Table 2).After primary esophagectomy, median time to recur-

ence was 12 months (IQR 6 to 21). Recurrence was de-ected within the first 12 months after resection in 70 pa-ients (56%), by 24 months in 104 (82%), and by 36onths in 118 (93%) (Fig. 3). Median time to recurrence

ased on the stage of disease is shown in Table 3. Recur-ence was detected significantly earlier in patients withore advanced disease (p � 0.04). Recurrence was sys-

emic in 76 patients (60%), locoregional and/or nodal in8 (30%), and both in 13 (10%). Systemic recurrence oc-urred significantly earlier than locoregional and/or nodalecurrence (9 months versus 15 months, respectively, p �.01). The most common sites of systemic recurrence werehe liver (57%), lung (18%), bone (8%), adrenal (5%),rain (3%), and other (11%).After neoadjuvant therapy, we categorized patients based

n the final pathology into those with complete pathologicesponse, residual disease limited to the esophagus, or re-idual disease in lymph nodes or the esophagus, or both.

edian time to recurrence after esophagectomy in patientsho had neoadjuvant therapy was 8 months (IQR 4 to 15).ecurrence developed within the first 12 months in 31pa-

ients (66%), within 24 months in 45 (96%), and within6 months of resection in 46 (98%) (Fig. 4). Median time

in patients who had primary esophagectomy andectomy. The time to 50% and 90% of recurrences

omyophag

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431Vol. 210, No. 4, April 2010 Abate et al Recurrence after Esophagectomy for Adenocarcinoma

hown in Table 4. Recurrence occurred significantly soonern patients with any residual disease (residual disease lim-ted to the esophagus or residual disease in lymph nodes orhe esophagus, or both) compared with those with com-lete pathologic response (p � 0.03). Recurrence was sys-emic in 28 patients (60%), locoregional and/or nodal in3 (28%), and both in 6 (12%) patients. Systemic recur-ence occurred earlier than locoregional and/or nodal re-urrence (6 months versus 11 months, respectively; p �.3). The most common sites of systemic recurrence were

iver (46%), lung (26%), bone (7%), brain (4%), adrenal4%), and others (11%).

urvivalverall 5-year survival in the 174 patients with recurrenceho were followed at our center using the standard proto-

ol was 19%, and median survival time was 20 monthsrange 11 to 35 months). Median survival from the time ofurgical resection was significantly longer in patients whoad primary resection compared with those who had neo-

able 2. Type of RecurrencePrimary surgery

(n � 127)n %

ystemic 76 60ocoregional 38 30

Figure 2. Frequency of recurrences occurring

oth 13 10

djuvant therapy before resection (21 versus 14 months,espectively; p � 0.03). However, median survival afterecurrence was identified was only 7 months (IQR 3 to 16onths), and was similar in patients after primary resection

nd neoadjuvant therapy (7 months versus 6.4 months,espectively; p � 0.18). Survival after recurrence correlatedith the interval from esophagectomy to detection of re-

urrence in patients who had primary resection, but wasoorly correlated in patients after neoadjuvant therapyFig. 5). The majority of patients (70%) received treatmentor their recurrent cancer, and survival was substantiallymproved in these patients (Fig. 6). Median survival inatients treated for recurrence was 9 months, comparedith 3 months in those untreated (p � 0.001). Treatment

or recurrence consisted of chemo- or chemoradiotherapyn 95 patients (78%) and surgical resection of nodal recur-ence or a metastatic focus in 22 patients (22%) plushemo- and/or radiotherapy after resection (Table 5). Me-ian survival for the 22 patients who had resection as partf the therapy for their recurrence was significantly longer

Neoadjuvant �esophagectomy (n � 47)

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ompared with patients treated with only chemo- or che-oradiotherapy for recurrence (18 versus 9 months, re-

pectively; p � 0.04). Without treatment, no patient sur-ived beyond 8 months once recurrence developed.

ISCUSSIONntrinsic to the care of a patient with cancer is a plan ofollow-up after therapy. For many cancers, there is a generalnderstanding of an appropriate follow-up protocol inerms of the timing of follow-up visits and useful bloodork, scans, or other tests. However, there has been littleublished about follow-up protocols for esophageal cancer,erhaps in part because of the dismal prognosis this diag-osis imparted on most patients in the past. Although stilldeadly disease, advances in the areas of earlier diagnosis

nd more effective therapies have led to an increasing num-

igure 3. Recurrence after primary esophagectomy (n � 127). Theumulative incidence of recurrence by stage: stage I: 14.3%, 71.4%,nd 100% at 1, 2 and 3 y; stage II: 40%, 66.7%, and 80% at 1, 2 andy; and stage III: 63.3%, 87.7%, and 96.6% at 1, 2 and 3 y.

er of long-term survivors and so an appropriate follow-up a

trategy has become relevant. The ideal cancer follow-uptrategy is one that detects recurrent or metastatic disease intimely fashion so that therapy can be initiated before

egradation of performance status or progression of diseaseeyond any chance of cure. However, the benefit of timelyiagnosis must be balanced by the inconvenience, cost, andotential side effects related to frequent office visits, bloodork, and radiation exposure that many tests entail.As an initial foray into determining an oncologically

ound, efficient, and cost-effective protocol for followingatients after esophagectomy for adenocarcinoma of theistal esophagus or gastroesophageal junction, we reviewedhe records of patients who had consistent follow-up at ourenter and in whom recurrence or metastatic disease devel-ped. We found that a surprisingly high percentage of re-urrences occurred very early after resection. Median timeo recurrence after esophagectomy in all patients was 11onths, and was 8 months in patients who had neoadju-

ant therapy, and 12 months after primary resection. Weould have liked to have been able to analyze recurrence

rom the date of diagnosis of the disease, but this often wasot clear in the records, although the date of resection wasnown in all patients. Assuming that esophagectomy inost neoadjuvant protocols is delayed 3 to 4 months, it is

ikely that had we been able to calculate the time to recur-ence from the date of diagnosis of the disease, there wouldave been no difference between patients who had primaryurgery or neoadjuvant therapy followed by resection. Inther words, it is unlikely that neoadjuvant therapy is caus-ng recurrences to occur earlier, but in those who did recurhere was also no evidence that neoadjuvant therapy de-ayed time to recurrence compared with those who hadrimary resection. Importantly, we are not commenting onhe overall efficacy of neoadjuvant therapy because this

able 3. Time to Recurrence in Primary Surgery Patientsased on Tumor Characteristics (n � 127)

Time to recurrence, mo p Value

tageI 21 (15�28)II 14 (6�35) 0.04III 9 (6�18)

ymph node statusN0 17 (13�32) 0.03N1 10 (6�19)o. of involved lymph nodes0 17 (13�32)1�2 11 (6�19) 0.043�7 10 (6�20)�8 9 (5�18)

ata reported as median (interquartile range).

nalysis is restricted to only those patients in whom recur-

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433Vol. 210, No. 4, April 2010 Abate et al Recurrence after Esophagectomy for Adenocarcinoma

ence developed. In addition, those that received neoadju-ant therapy in this series tended to have more advancedisease.In patients who had neoadjuvant therapy before esoph-

gectomy, the peak time frame for recurrence was in theirst 3 months, and �90% of recurrences had occurred by1 months. In patients who had primary esophagectomy,he peak time interval for detection of recurrence was 6 tomonths, and �90% of recurrences were detected by 33onths after esophagectomy. Not surprisingly, the time to

ecurrence was impacted by the stage of disease, with aubstantially shorter interval from resection to recurrencen patients with more advanced disease after primarysophagectomy. Likewise, the time to recurrence was con-iderably shorter in patients with residual disease after neo-djuvant therapy compared with those who had a patho-ogic complete response.

Our results can be used to counsel patients in theollow-up clinic about where they stand with their disease.sing the data from Figures 1, 3, and 4, patients can be toldhen they have passed the point where 50% and 90% of

igure 4. Recurrence after neoadjuvant therapy (n � 47). The cu-ulative incidence of recurrence by response: pathologic complete

esponse (pCR): 40%, 80%, and 80% at 1, 2, and 3 y; residualisease in esophagus only (RD eso): 50% and 100% at 1 and 2 y;nd RD in lymph nodes � esophagus (RD LN � eso): 86.7%, 96.7%,nd 100% at 1, 2, 3 y.

ecurrences have occurred, based on their type of therapy j

nd stage of disease. Although this is no guarantee that theyill not have recurrences subsequently, this type of infor-ation is welcomed by patients who typically approach

ach cancer follow-up visit with trepidation.Our results also provide guidance for a reasonable pro-

ocol for both the duration and frequency of follow-upfter resection for esophageal adenocarcinoma. The latestecurrence documented in this series was at 72 monthsfter primary resection. Consequently, follow-up out to 7ears is recommended after primary esophagectomy, andhis should be sufficient for all but the rare patient. Aftereoadjuvant therapy, the last recurrence was at 39 monthsnd follow-up in this group out to 5 years should be suffi-ient. The ideal frequency of follow-up, particularly earlyfter resection, is less easy to clarify. Frequent follow-upuring the first 2 years after resection appears warranted,nd every 3 months is probably about as often as is practi-al. Because the percentage of recurrences that occur atach interval drops off substantially after 2 years (Fig. 2), itppears reasonable to extend the follow-up interval to every2 months at that point, especially in those who had neo-djuvant therapy.

An interesting group is those with stage I adenocarci-oma after resection alone. In the small number of patientsho had recurrences, all were detected within 3 years. This

uggests that long-term follow-up in this group is not nec-ssary because they either recur relatively early or not at all.n contrast, those with higher-stage lesions recurred out to

years, and protracted follow-up is necessary. A recom-ended follow-up strategy based on the type of therapy

nd stage of disease is shown in Table 6.It is clear from our data that in those who had a recur-

ence, neoadjuvant therapy did not delay onset of recur-ence. In addition, although neoadjuvant chemotherapyas associated with a reduction in systemic disease in theAGIC (Medical Research Council Adjuvant Gastric In-

usional Chemotherapy) trial from the United Kingdom,4

nd use of neoadjuvant chemoradiotherapy was associatedith reduced locoregional recurrence in a randomized trial

n the United States,5 we found no substantial differencesn the type of recurrence between patients who had neoad-

able 4. Time to Recurrence in Patients Who Had Neoadju-ant Therapy before Resection (n � 47)tage Time to recurrence, mo p Value

CR 19 (8�30)D eso 12 (7�19) 0.03D LN � eso 6 (3�9)

ata reported as median (interquartile range).CR, pathologic complete response; RD eso, residual disease in the esophagusnly; RD LN � eso, residual disease in the lymph nodes and the esophagus.

uvant therapy and those who had primary resection. In

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oth groups, the majority of recurrences were systemic, andhe pattern of systemic metastases was also similar, with theiver being the most common site. The purpose of thisnalysis was not to see if neoadjuvant therapy reduced theverall frequency of recurrence, but it was disappointing toee how quickly cancer recurred after neoadjuvant therapyn those who had a recurrence. A potential explanation forhese findings is that the chemotherapy impairs host im-unity, so that if the chemotherapy is ineffective the dis-

ase progresses rapidly. Interestingly, even in those withomplete pathologic response, when recurrence occurred itas early, pointing to the likelihood that occult systemicisease had not been eradicated in these patients.Another goal of this study was to assess the use of routine

igure 5. Survival as a function of time to recurrence for patientsho had primary esophagectomy, triangle (n � 127); Pearson r �.3180, p � 0.0003, dashed line; and those who had neoadjuvantherapy, dot (n � 47); Pearson r � 0.05721, p � 0.7025, solid line.urvival after recurrence in the primary surgery group was substan-ially correlated with time from the esophagectomy, but some pa-ients with early recurrence had prolonged survival.

lood work, including CEA level and CT scans of the chest d

nd abdomen at each follow-up visit. Because the majorityf recurrences were systemic and detected by CT scan, aaseline contrast CT scan of the chest and abdomen shoulde obtained at the first 3-month visit and then, in thoseithout evidence of disease on this scan, evaluation of the

iver with ultrasound rather than an abdominal CT scanould be reasonable, particularly for the first year because

ocoregional recurrence occurred later than systemic recur-ence. Likewise, noncontrast CT of the chest could be usedo evaluate for lung metastases for the first year of follow-p, reserving contrast for detection of locoregional recur-ence beyond the first year. Routine CEA levels were sel-om useful, but in a few patients marked elevation diduggest the presence of disease before identification of re-urrence on any scans. However, in the absence of identi-iable recurrence on CT or PET scans, patients wereot treated and, therefore, routine CEA testing during

ollow-up is probably not useful. On the other hand, al-hough PET scans were obtained by only some of the sur-eons in this study, and only annually in the patients whoere receiving them, PET was the first test to identify re-

urrence in 18% of patients, and more liberal use of fusionT-PET for follow-up is worth exploring in future studies,articularly in patients with renal insufficiency, where con-rast CT scans are problematic.

Importantly, follow-up only makes sense if somethingan be done to improve survival or quality of life whenecurrence is identified. Although median survival afteretecting recurrence was poor, we showed that survival wasonsiderably better in those who had therapy for their re-urrence. In nearly all cases, those that did not have therapyere those with widespread disease and/or poor perfor-ance status; but the fact that 16% of recurrences were

menable to resection suggests that often recurrence was

igure 6. Survival after recurrence in patients either treated or notreated for their recurrence.

etected early enough to intervene effectively. In addition,

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435Vol. 210, No. 4, April 2010 Abate et al Recurrence after Esophagectomy for Adenocarcinoma

s shown in Figure 5, even early recurrence can be associ-ted with prolonged survival. This is important becauseatients and physicians can often be tempted to give uphen the disease recurs early after resection, but our data

ndicate that aggressive therapy is warranted and leads toeaningful survival in some patients. Although a random-

zed trial of routine follow-up versus no follow-up couldnswer the question definitively, it is difficult to imagine aatient with cancer agreeing not to have routine follow-upfter therapy. Instead, using our data as a guide, patientsould be randomized to different intervals of follow-up andypes of testing, particularly given the inconvenience, dis-omfort, and potential hazards of radiation exposure thatccompany many of the follow-up studies in routine use for

able 5. Site of Recurrence, Treatment, and Survival in 174 Pite of recurrence n Treatment given after d

solated to single organ or area 22 Resection � chemoradiCervical or abdominal nodes 13Brain 1Liver 3Adrenal 2Bone (mandible) 1Thyroid 1Anastomosis 1ultifocal (�1 location) 152 Chemotherapy, 95

None, 57

able 6. Recommended Follow-up Strategy after Esopha-ectomy for Adenocarcinomaollow-up,o

Primaryesophagectomy

Neoadjuvant therapy �esophagectomy

3 1 and 2 1 and 26 (1 or 3, 4) or 5 (1 or 3, 4) or 59 1 or 3, 4 1 or 3, 42 1 and 2, 5 1 and 2, 55 1 and 2 1 and 28 1 and 2, or 5 1 and 2, or 51 1 and 2 1 and 24 1 and 2, or 5 1 and 2, or 57 — —0 1 and 2, or 5 —3 — —6 1 and 2, or 5 1 and 2, or 58 1 and 2, or 5 1 and 2, or 50 1 and 2, or 5* 1 and 2, or 52 1 and 2, or 5 —4 1 and 2, or 5 —

, contrast CT of abdomen; 2, contrast CT of chest; 3, abdominal and rightpper quadrant ultrasound; 4, noncontrast CT of chest; 5, fusion CT-PETcan.

After primary resection, can end follow-up for stage I patients at 5 years.

atients with esophageal cancer. Comparing the efficacy ofifferent follow-up protocols with a cost analysis of eachould be a useful and important next step in the manage-ent of patients with esophageal adenocarcinoma.After esophagectomy, recurrence of adenocarcinoma of the

sophagus or gastroesophageal junction is often within theirst year, and �90% of recurrences have been detected by 2ears after neoadjuvant therapy and 3 years after primary re-ection. Follow-up during these years should be frequent, be-ause detection and treatment of recurrence can lead to mean-ngful survival in some patients. Overall, the best test todentify both systemic and locoregional recurrence is aontrast-enhanced CT scan of the chest and abdomen.

uthor Contributions

tudy conception and design: Abate, S DeMeester, Hagen, TDeMeester

cquisition of data: Abate, Zehetner, Oezcelik, Ayazi, Cos-tales, Banki

nalysis and interpretation of data: Abate, Zehetnerrafting of manuscript: Abate, S DeMeester, Zehetner, Liphamritical revision: S DeMeester, Hagen, T DeMeester

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