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SSAT Patient Care Guidelines

Surgical Treatment Of Esophageal Cancer

Introduction
Esophageal carcinoma is a relatively uncommon but highly lethal malignancy comprising 5% of gastrointestinal cancers in the U.S. It is estimated that over 12,000 patients will develop carcinoma of the esophagus in the U.S each year. In most Western countries the prevalence of esophageal carcinoma is increasing at a rate of approximately 10% per year, which is faster than any other malignancy. The disease has also undergone a profound epidemiologic change, from predominantly squamous cell carcinoma seen in association with tobacco and alcohol abuse, to that of adenocarcinoma in the setting of gastroesophageal reflux disease (GERD) and Barrett's metaplasia. This sequence from GERD to intestinal metaplasia to dysplasia to adenocarcinoma has now been recognized and is translating to a better understanding of and improved treatment for this disease. By contrast, the incidence of squamous cell carcinoma of the esophagus is stable or diminishing.

Symptoms and Diagnosis
Dysphagia is the most common presenting symptom and usually manifests as difficulty swallowing hard, solid foods (i.e. meats and bread) with ultimate progression to softer foods and liquids. Odynophagia, regurgitation and weight loss are also commonly described in advanced cases. Local tumor extension invading into the tracheobronchial tree or recurrent laryngeal nerves can result in stridor, cough, choking, aspiration pneumonia and hoarseness. Physical exam is usually normal, but may reveal signs of generalized wasting as a consequence of poor nutrition or metastatic disease. Tumors are now being increasingly diagnosed in earlier stage patients without dysphagia who have been followed because of reflux or Barrett’s esophagus in programs of surveillance endoscopy.

A systemic approach to the diagnosis and staging of esophageal cancer is mandatory. Once a histologic diagnosis of esophageal carcinoma has been confirmed by endoscopic biopsy, a detailed staging evaluation of the local, regional and metastatic extent of the disease is performed. CT scans of the chest and abdomen are useful to search for metastatic disease. Endoscopic ultrasound should be performed to evaluate depth of tumor invasion in the esophageal wall and regional nodal involvement. Its accuracy in disease detection is approximately 80-85% for tumor depth and 70-75% for nodal status FDG-PET scans may help to identify unsuspected metastatic disease. Accurate staging prior to treatment is important not only for survival analyses, but also for clinical decision-making.

Treatment
Treatment may be either curative or palliative, depending on the stage of the disease and the patient's condition. Curative treatment is most applicable to early lesions. If the lymph node spread is limited, even moderately advanced tumors may be cured by surgery. The earliest forms of cancer—high grade dysplasia and cancer contained within the mucosa—may be treated by an esophagectomy with a high expectation of cure. Therapies directed at ablating the mucosa endoscopically for early cancer are still experimental. For more advanced but still potentially curable cancers, five year survival rates as high as 41% have been reported. For patients with locally advanced (stage III) disease, long-term survival can be achieved in 25-35% of patients following esophagectomy. Esophagectomy can be performed by either transthoracic or transhiatal approaches. Morbidity and mortality rates are now less than 5% as a result of improvements in surgical technique and perioperative care when performed at high volume esophageal referral centers. The addition of chemotherapy or radiotherapy after operation (adjuvant therapy) has not been shown to be beneficial. The preoperative administration of chemotherapy and radiation (neo-adjuvant therapy) is gaining in popularity, and may possibly be superior to surgery alone in appropriately selected and staged patients with locally advanced cancer but the evidence is not strong. The morbidity of the surgery does not appear to be increased by the use of preoperative therapy even in the elderly when performed in high volume centers.

In patients with advanced cancers, the disease is essentially incurable and the focus shifts towards palliation. If the tumor is resectable the best palliation is generally obtained by surgery. In unresectable tumors or where distant metastases are present, the survival is much shorter and excisional surgery is rarely justified. Dysphagia or tracheoesophageal fistula can be fairly well palliated by a stent inserted endoscopically.

Risks and Expected Outcomes
Data suggest that esophagectomy is most safely performed in high volume units. The mortality rate of esophagectomy is 2-6% in such centers. However, serious complications are frequent and may occur in 20-40% of cases—the most common being pulmonary (10-50%), cardiac dysrhythmias (10%), and anastomotic leak (5-10%). When the anastomosis is made in the neck, a leak is rarely the cause of serious morbidity. However, dissection in the neck does carry the potential risk of temporary or even permanent recurrent laryngeal nerve injury. Average hospital stay following esophagectomy is 10-14 days.

Overall 5-year survival after resection is approximately 20-35%. For patients with early tumors limited to the mucosa 5-year survival rates can exceed 80%. Patients free of lymph node metastases have 5-year survivals of 60%, whereas survival decreases to 10-20% in lymph node positive patients. Palliative resection provides relief of dysphagia in 90% of patients.

Qualifications of Personnel Providing Care or Surgery
The qualifications of a surgeon to perform any operative procedure should be based on education, training, experience, and outcomes. At a minimum, the surgical treatment of esophageal cancer should be performed by surgeons who are certified or eligible for certification by the American Board of Surgery, the Royal College of Physicians and Surgeons of Canada, or the equivalent. These surgeons have successfully completed at least 5 years of surgical training after medical school graduation and are qualified to perform operations on the esophagus and stomach. When performing laparoscopic esophageal surgery, it is highly desirable that the surgeon has advanced laparoscopic skills. The level of training in advanced laparoscopic techniques necessary to conduct minimally invasive surgery is important to assess.

Suggested Readings
Lagergren J, Bergstrom R, Lindgren A and Nyren O. Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. NEJM, 1999; 340:825-831.

Nigro JJ, DeMeester SR, Hagen JA, et al. Node status in transmural esophageal adenocarcinoma and outcome after en-bloc esophagectomy. J Thorac Cardiovasc Surg 1999; 117:960-968.

Patti MG, Corvera CU, Glasgow RE, Way LW. A hospital's annual rate of esophagectomy influences the operative mortality rate. J Gastrointest Surg 1998; 2:186-192

Jemal A, Tiwari RC, Murray T, et al. Cancer Statistics 2004. Cancer J Clin 2004; 54_8-29.

Flamen P, Lerut A, Van Cutsem E, et al. Utility of positron emission tomography for the staging of patients with potentially operable esophageal carcinoma 2000; 18:3202-3210.

Hofstetter, W., Swisher, S.G., Correa, A.M., et al. Treatment outcomes of resected esophageal cancer. Ann. Surg., 236:376-385, 2002.

Hulscher JBF, Van Sandick JW, de Boer AGEM, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med 2002; 347:1662-1669.

Rice, D.C., Correa, A.M., Vaporciyan, A.A., et al. Preoperative chemoradiotherapy prior to esophagectomy in elderly patients is not associated with increased morbidity. Ann. Thorac. Surg., in press, 2004.

Urba SG, Orringer MB, Turrisi A, et al. Randomized trial of preoperative chemoradiation versus surgery alone in patients with locoregional esophageal carcinoma. J Clin Oncol. 2001; 19:305-313.

Weber WA, Ott K. Imaging of esophageal and gastric cancer. Semin Oncol 2004; 31:530-541.

Originally written 10/00
Revised 1/25/01
Revised 3/1/01
Board Approved 10/7/02
Revised 10/12/04
Revised 1/20/05
Board Approved 5/14/05

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Disclaimer
SSAT Patient Care Committee Guidelines

These patient care guidelines were written for the primary care physicians on a variety of digestive diseases to assist on when to refer the patient for surgical consultation.
Their goal is to guide PRIMARY CARE physicians to the appropriate utilization of surgical procedures on the alimentary tract or related organs and they are based on critical review of the literature and expert opinion. Both of the latter sources of information result in a consensus that is recorded in the form of these Guidelines. The consensus addressses the range of acceptable clinical practice and should not be construed as a standard of care. These Guidelines require periodic revision to ensure that clinicians utilize procedures appropriately but the reader must realize that clinical judgment may justify a course of action outside of the recommendations contained herein.

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