P1.160. Role of Minimally Invasive Esophagectomy in Multidisciplinary Treatment for T4b Cervical Esophageal Cancer

Abstract

Esophageal Cancer: Surgical Treatment of Esophageal Cancer No standard treatment exists for T4b (UICC 8th) cervical esophageal cancer. At our institution, definitive chemoradiotherapy (dCRT) (total dose > 50.4 Gy) is prioritized as initial therapy, and salvage surgery is performed only for persistent or recurrent disease. This strategy aims to maximize organ preservation while maintaining oncologic safety in this anatomically complex region. We retrospectively reviewed outcomes of patients with T4b cervical esophageal cancer who underwent surgery between 2008 and 2024. Minimally invasive subtotal/total esophagectomy was the primary approach for lesions extending below the upper thoracic esophagus. In salvage cases and pharyngogastric anastomosis, microvascular reconstruction was routinely added, while preserving the azygos arch and right bronchial artery. Among 58 patients with T4b cervical esophageal cancer, 55 received dCRT. Salvage surgery was performed in 10 patients (4 residual disease, 3 local recurrence, 3 after induction chemotherapy). Tumor location was Ce/CePh/CeUt/CePhUt = 2/1/5/2. Approaches were thoracoscopic (n=6), robotic (n=2), and mediastinoscopic (n=2). All underwent subtotal (n=2) or total esophagectomy with pharyngo-laryngectomy (n=8) with posterior mediastinal gastric conduit reconstruction. Vascular reconstruction was performed in 9 cases, and R0 resection was achieved in all. Complications were grade II anastomotic leakage in 4 and grade IIIa pleural effusion in 1, with no operative mortality and no recurrent laryngeal nerve palsy in larynx-preserving cases. Four developed distant recurrence. Three-year overall survival was 100% in surgical patients and 65.1% in the entire dCRT cohort. Although salvage surgery carries a high risk of leakage, complications were manageable. This approach is feasible and oncologically safe, allowing laryngeal preservation in 20% of cases. Three-year overall survival was 100% after surgery and approximately 65% for the overall dCRT cohort. A strategy prioritizing dCRT followed by minimally invasive salvage esophagectomy for residual or recurrent disease appears promising for T4b cervical esophageal cancer.