The questions related to a 63 year old man who was diagnosed with a distal esophageal adenocarcinoma 9 months prior to referral, initially staged as T3N1 via EUS, CT, and PET. His general health at the time of diagnosis was good. He was not evaluated by a surgeon at that time, and underwent definitive chemotherapy (4 cycles of platinum-based therapy) and 5040 cGy of radiation therapy, both ending 6 months prior to referral. At the time you see him, he has persistent mild dysphagia and a persistent mass in his distal esophagus on CT.

Almost 90% of respondents would perform a PET scan for additional evaluation, while about 50% would get an EUS, an EGD, and/or PFTs. Interest in a barium swallow was low, with only 15% of respondents recommending this evaluation.

A small number of respondents either didn’t believe salvage esophagectomy is an appropriate operation or don’t perform the operation. Of the respondents who do perform salvage esophagectomy, about one-third would require proof of persistent disease before proceeding, while two-thirds would proceed based on existing information.

When performing a salvage esophagectomy, the vast majority of respondents would use an open transthoracic approach. Almost 20% would use a minimally invasive approach, and 10% would use a transhiatal approach. Almost 80% of respondents would describe the operation as carrying increased or substantially increased risk.

Long-term outcomes were described as unknown by 70% of respondents, whereas results were described as similar to or worse than standard esophagectomy by 10% of respondents each.

1. What additional evaluation would you recommend for this patient? Check all that are appropriate.
	answered question		115
	skipped question		1
		Response Percent	Response Count
PET		88.7%	102
EUS		54.8%	63
EGD		53.0%	61
Barium swallow		16.5%	19
Pulmonary function tests		54.8%	63

2. Assuming there is no evidence for metastatic disease or technical unresectability, which statement best reflects your approach to this patient?
	answered question		116
	skipped question		0
		Response Percent	Response Count
I don’t think salvage esophagectomy is ever indicated.		5.2%	6
Although salvage esophagectomy may be indicated, I don’t perform this operation.		9.5%	11
I would not perform a salvage esophagectomy unless persistent cancer was diagnosed.		32.8%	38
I would recommend salvage esophagectomy regardless of whether persistent cancer was diagnosed.		52.6%	61

3. In performing a salvage esophagectomy, what surgical approach is optimal in this patient?
	answered question		116
	skipped question		0
		Response Percent	Response Count
Ivor Lewis type (laparotomy, thoracotomy)		65.5%	76
Transhiatal		10.3%	12
Exclusive transthoracic		4.3%	5
Minimally invasive (totally minimally invasive or hybrid)		19.8%	23

4. What surgical risk would you discuss with this patient?
	answered question		115
	skipped question		1
		Response Percent	Response Count
Surgical risk is similar to that for conventional esophagectomy		19.1%	22
Surgical risk is somewhat increased compared to conventional esophagectomy		45.2%	52
Surgical risk is substantially increased compared to conventional esophagectomy		35.7%	41

5. What long-term results would you discuss with this patient?
	answered question		115
	skipped question		1
		Response Percent	Response Count
Cancer survival is similar to patients who have conventional multimodality therapy.		14.8%	17
Cancer survival is definitely worse compared to patients who have conventional multimodality therapy.		14.8%	17
Cancer survival after salvage esophagectomy in this situation is not known.		70.4%	81

6. In what region do you practice?
	answered question		115
	skipped question		1
		Response Percent	Response Count
North America		61.7%	71
Europe		16.5%	19
Asia		13.0%	15
Africa		2.6%	3
Central or South America		6.1%	7
Australia/New Zealand		0.0%	0