Esophageal cancer surgery

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]

Overview[edit | edit source]

The predominant therapy for esophageal cancer is surgical resection by esophagectomy. The disease must be localised in order for it to be operable. Adjunctive chemotherapy and radiation may be required in more advanced cases of esophageal cancer, and to shrink down a localised tumor so that it may become operable.

Esophagectomy[edit | edit source]

• Removing a segment of the esophagus is called an esophagectomy.^[1][2][3]
• The disease must be localised in order for it to be operable.
• If a tumor is particularly large but still localised, it may be shrunk down first using chemotherapy and/or radiotherapy until the tumor becomes of a size that is operable.
• The procedure shortens the distance between the pharynx and the stomach.
• The stomach, or some other part of the gastrointestinal tract, such as the colon, is brought up into the chest cavity where it is interposed.
• There are several surgical approaches including:
  • Transhiatal esophagectomy
  • Cervical esophageal cancer resection
  • Thoracic cancer resection
  • Ivor-Lewis transthoracic esophagectomy
  • Modified Ivor-Lewis transthoracic esophagectomy
  • Tri-incisional esophagectomy
  • Esophagogastric junction cancer resection

Surgical Considerations[edit | edit source]

• Patients with resectable tumors account for 20-30% of cases with esophageal cancer.^[2][3]
• In patients with adenocarcinoma, surgery is recommended even if there is a good response with chemotherapy. Surgery achieves a higher rate of local control and less need for palliative maneuvers later on.
• Patients in this category should undergo surgery after having completed 4 to 6 weeks of chemotherapy or chemoradiotherapy.
• Unless, the patient is able to achieve cure without surgery or is unfit for surgery.

Indications[edit | edit source]

• The following are candidates for first line therapy with esophagectomy:^[4][5]
  • T1N0M0 lesions
  • T2N0M0 lesions
• The patients with the following are candidates for esophagectomy following neoadjuvant chemotherapy or chemoradiotherapy:
  • Thoracic esophageal or esophagogastric junction tumors and full-thickness (T3) involvement of the esophagus with/without nodal disease
  • T4a disease with invasion of local structures (pericardium, pleura, and/or diaphragm only) that can be resected en bloc, and who are without evidence of metastatic disease to other organ.

Contraindications[edit | edit source]

The following are relative contraindications for esophagectomy:^[6]

• Advanced age
  • Associated with greater morbidity following esophagectomy
• Comorbid illness
  • Obesity can lead to postoperative complications such as cardiorespiratory complications, anastomotic leakage, and wound infection

Indications for unresectability[edit | edit source]

The presence of metastatic disease:

• Such as peritoneal, lung, bone, adrenal, brain, or liver metastases, or extraregional lymph node spread

Surgery[edit | edit source]

Stage 0 Esophageal Cancer[edit | edit source]

Stage 0 squamous esophageal cancer is rarely seen in the United States, but surgery has been used for this stage of cancer^[7]

Stage I Esophageal Cancer[edit | edit source]

Standard treatment options:

• Chemoradiation with subsequent surgery
• Surgery

Stage II Esophageal Cancer[edit | edit source]

Standard treatment options:

• Chemoradiation with subsequent surgery
• Chemoradiation alone
• Surgery alone

Stage III Esophageal Cancer[edit | edit source]

Standard treatment options:

• Chemoradiation with subsequent surgery
• Chemoradiation alone

Stage IV Esophageal Cancer[edit | edit source]

• At diagnosis, approximately 50% of patients with esophageal cancer will have metastatic disease and will be candidates for palliative therapy.^[8]
• Standard treatment options:
  • Chemoradiation with subsequent surgery (for patients with stage IVA disease)
  • Endoscopic-placed stents to provide palliation of dysphagia
  • Radiation therapy with or without intraluminal intubation and dilation
  • Intraluminal brachytherapy to provide palliation of dysphagia
  • Nd:YAG laser endoluminal tumor destruction or electrocoagulation
  • Chemotherapy has provided partial responses for patients with metastatic distal esophageal adenocarcinoma

Stenting[edit | edit source]

• If the patient cannot swallow at all, a stent may be inserted to keep the esophagus patent.^[9]
• Stents may also assist in occluding fistulas.
• A nasogastric tube may be necessary to continue feeding while treatment for the tumor is given, and some patients may require a gastrostomy (feeding hole in the skin that gives direct access to the stomach).
• Nasogastric tube and gastrostomy are especially important if the patient tends to aspirate food or saliva into the airways, predisposing for aspiration pneumonia.

Laser therapy[edit | edit source]

• Laser therapy is described as the use of a high intensity beam of light to destroy malignant cells; it affects only the area it is focused on whilst unharming the healthy cells.^[10][11]
• Laser therapy is given when tumors are inoperable because of their size, location and/or spread.
• Sometimes, the aim of laser therapy is palliation, to relieve some symptoms such as dysphagia and pain.
• Photodynamic therapy (PDT), a type of laser therapy, involving the use of drugs that are absorbed by cancer cells; when exposed to a particular wave length of light, the drugs become active and destroy the tumor cells.

Radiotherapy[edit | edit source]

• Radiotherapy is given before, during or after chemotherapy or surgery, and sometimes on its own to control symptoms.^[12][13]
• In patients with localized disease but contraindications to surgery, "proton radiotherapy" may be used with curative intent.

References[edit | edit source]

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