Objective: This study aimed to evaluate the feasibility and safety of surgical intervention for patients with stage Ⅳ esophageal cancer who demonstrated tumor regression following first-line treatment. Methods: This was a descriptive case series. The inclusion criteria for surgery were as follows: (1) an initial diagnosis of stage Ⅳ esophageal cancer, i.e. cT4b or cM1; (2) the presence of residual tumor following first-line therapy deemed potentially resectable upon reassessment; and (3) sufficient organ function to tolerate surgical procedures. Clinical data were retrospectively collected for 63 patients with stage Ⅳ esophageal cancer who underwent surgery following first-line therapy at Sun Yat-sen University Cancer Center between January 2014 and December 2023. Of these patients, 12 were initially staged as IVA, and 51 as IVB. Post-treatment restaging revealed that 9 patients achieved a clinical complete response, while 3 were downstaged to stage Ⅰ, 14 to stage Ⅱ, 24 to stage Ⅲ, and 13 to stage ⅣB (with regression of distant metastatic lesions enabling curative resection). Surgical approaches included right thoracic esophagectomy (n=55), left thoracic esophagectomy (n=4), and transmediastinal esophagectomy (n=4). Additionally, 7 patients required extended organ resection. Two-field lymph node dissection was performed in 49 patients, while 14 underwent three-field lymph node dissection. Postoperative management varied: 31 patients received no adjuvant therapy, 11 underwent immunochemotherapy, 8 received immunotherapy alone, 8 underwent chemotherapy, 4 received chemoradiotherapy, and 1 received combined radiotherapy and immunotherapy. The primary endpoints were overall survival (OS) and progression-free survival (PFS), with secondary endpoints including surgical outcomes and postoperative complications. Results: All 63 patients successfully underwent surgery without intraoperative mortality. R0 resection was achieved in 58 cases (92.1%), while R1 and R2 resections were performed in 1 case (1.6%) and 4 cases (6.3%), respectively. The mean operative time was 357±135 minutes. Postoperative complications were observed in 27 cases (42.9%), with 9 cases (14.3%) classified as Clavien-Dindo grade Ⅲ or Ⅴ. One patient (1.6%) died perioperatively. The median follow-up duration was 21 months (range: 4-107 months). The median OS was 64.8 months (95% CI: 50.9-78.6 months), and the median PFS was 68.0 months (95% CI: 53.9-82.3 months). Among 24 patients with supraclavicular lymph node metastases, 6 experienced recurrence and 8 died. Of 25 patients with abdominal metastases, 3 had recurrence and subsequently died. All 4 patients with lung metastases and both patients with bone metastases experienced recurrence and death. Conclusions: Surgical intervention is a feasible and safe treatment option for selected patients with stage Ⅳ esophageal cancer who demonstrate the potential for curative resection following first-line therapy.
目的： 评价一线治疗后Ⅳ期食管癌患者行手术治疗的可行性及安全性。 方法： 本研究为描述性病例系列研究。手术的选择标准如下：（1）初始诊断为cT4b或cM1的Ⅳ期食管癌患者，已接受一线治疗；（2）治疗后仍有肿瘤残留，经重新评估可能可以达到根治性切除；（3）重要器官功能正常，可耐受手术治疗。根据上述标准，收集2014年1月至2023年12月期间，于中山大学肿瘤防治中心一线治疗后接受手术的63例Ⅳ期食管癌患者临床资料，包括治疗前ⅣA期患者12例，ⅣB期患者51例。一线治疗后，9例被评估为临床完全缓解（cCR），3例降期为Ⅰ期，14例降期为Ⅱ期，24例降期为Ⅲ期，13例降期为ⅣB期但远处转移病灶退缩，经评估可达到根治性切除。全组患者经右胸食管癌切除55例，经左胸及纵隔食管切除各4例。扩大器官切除7例。二野淋巴结清扫49例，三野淋巴结清扫14例。术后未做任何治疗31例，接受免疫治疗联合化疗11例，免疫单药治疗8例，单纯化疗8例，放化疗4例，免疫治疗联合放化疗1例。主要观察指标为患者总体生存（OS）和无进展生存（PFS），其他观察指标包括手术情况及术后并发症发生情况。 结果： 全组63例患者均顺利完成手术，无术中死亡。58例（92.1%）为R0切除，1例（1.6%）为R1切除，4例（6.3%）为R2切除，手术时间为（357±135）min。共有27例（42.9%）发生术后并发症，9例（14.3%）为Clavien-Dindo Ⅲ~Ⅴ级并发症，1例（1.6%）患者围手术期间死亡。本组患者中位随访时间为21（4~107）个月，中位OS为64.8（95%CI：50.9~78.6）个月，中位PFS为68.0（95%CI：53.9~82.3）个月。24例锁骨上淋巴结转移患者中，6例复发，8例死亡；25例腹腔区域转移患者中，3例复发并死亡；4例肺转移和2例骨转移患者均复发并死亡。 结论： 对于经一线治疗后肿瘤降期并可能实现根治性切除的Ⅳ期食管癌患者，手术安全可行。.