Stage IV Esophageal Cancer: Room for Improvement?

Objective: This study aimed to assess short- and long-term outcomes in patients undergoing surgery for pathological stage IV esophageal cancer. Background Data: Esophageal cancer has a very poor prognosis in advanced stages, with 5-year survival rates below 6% in stage IV disease. Although current guidelines generally discourage surgery in metastatic patients, selected cases with oligometastatic disease may benefit from esophagectomy within a multimodal treatment framework. Methods: We retrospectively reviewed a prospectively maintained database of 437 esophagectomies performed between January 2013 and June 2024. Sixty patients with pathological stage IV esophageal carcinoma (AJCC 8th edition) were included, including adenocarcinoma, squamous cell carcinoma, and undifferentiated tumors. Patients were divided into stage IV-A ( n = 39) and stage IV-B ( n = 21), all of whom were oligometastatic according to the OMEC classification. The primary endpoints were overall survival (OS) and disease-free survival (DFS). Results: Median age was 63.5 years, and 61.7% of patients were male. Neoadjuvant chemoradiotherapy was administered in 48.3% of cases. Postoperative morbidity was 43.3%, and in-hospital mortality rate of 5%, showing no significant differences between groups. Median OS was significantly longer in stage IV-A compared with stage IV-B (18.0 versus 8.0 months, P = .003), as was median DFS (10.0 versus 3.0 months, P = .010). Among stage IV-B patients, survival differed according to metastatic site, with better outcomes in nodal-only disease. Conclusion: Esophagectomy may be feasible in highly selected stage IV patients, offering meaningful survival in stage IV-A cases, while outcomes in stage IV-B remain limited and influenced by metastatic pattern.