Future directions in esophageal cancer

Esophageal Carcinoma: Current Controversial Topics

Worldwide, esophageal carcinoma is a common gastrointestinal cancer with a high mortality. The incidence of adenocarcinoma of the esophagus is increasing in the western world, but squamous cell carcinoma remains dominant in the underdeveloped parts of the world. Both types of esophageal carcinoma remain equally virulent. Currently, there are no optimal preventative screening programs available and most patients present with advanced or metastatic disease. Although many options are available for improving diagnostic accuracy, a single method has not displayed significant advantages over the others. In addition, selecting a superior treatment regimen has not surfaced. Preferred resection techniques exist, but one method has not illustrated improvements in survival over the others. A lack of improved survival rates with single modality therapies has led to a multi modality approach. However, developments in neoadjuvant and adjuvant therapies have led to mixed conclusions. Collectively, past studies have not shown an optimal neoadjuvant or adjuvant regimen in terms of survival benefit. This review highlights existing staging modalities and treatment regimens for esophageal carcinoma, in an effort to illustrate the controversial nature surrounding its management.

Minimally invasive esophagectomy: outcomes in 222 patients

OBJECTIVE

To assess our outcomes after minimally invasive esophagectomy (MIE).

SUMMARY BACKGROUND DATA

Esophagectomy has traditionally been performed by open methods. Results from most series include mortality rates in excess of 5% and hospital stays frequently greater than 10 days. MIE has the potential to improve these results, but only a few small series have been reported. This report summarizes our experience of 222 cases.

METHODS

From 1996 to 2002, MIE was performed in 222 patients. Indications for operation included high-grade dysplasia (n = 47) and cancer (n = 175). Neoadjuvant chemotherapy was used in 78 (35.1%) and radiation in 36 (16.2%). Initially, a laparoscopic transhiatal approach was used (n = 8), but subsequently our approach evolved to include thoracoscopic mobilization (n = 214).

RESULTS

There were 186 men and 36 women. Median age was 66.5 years (range, 39-89). Nonemergent conversion to open procedure was required in 16 patients (7.2%). MIE was successfully completed in 206 (92.8%) patients. The median intensive care unit stay was 1 day (range, 1-30); hospital stay was 7 days (range, 3-75). Operative mortality was 1.4% (n = 3). Anastomotic leak rate was 11.7% (n = 26). At a mean follow-up of 19 months (range, 1-68), quality of life scores were similar to preoperative values and population norms. Stage specific survival was similar to open series.

CONCLUSIONS

MIE offers results as good as or better than open operation in our center with extensive minimally invasive and open experience. In this single institution experience, we observed a lower mortality rate (1.4%) and shorter hospital stay (7 days) than most open series. Given these results, we are now developing an intergroup trial (ECOG 2202) to assess MIE in a multicenter setting.

Obstruction of right ventricular outflow tract by extended cardiac metastasis from esophageal cancer

We report a patient in whom there was right ventricular outflow tract obstruction by extended metastasis from esophageal cancer. A 65-year-old man was admitted to the hospital for evaluation of recent onset of weight loss and heart murmur. Esophagogram and endoscopy showed a 10-cm, ulcerative, infiltrative esophageal cancer. This esophageal cancer was histologically proven to be a squamous cell carcinoma. To assess the cardiac metastasis, echocardiography, magnetic resonance imaging, coronary angiography, and endomyocardial biopsy were performed. The magnetic resonance imaging, echocardiography, and right ventriculography revealed a 7-cm lobulated mass extending to the right ventricular outflow tract, right ventricle, septum, and anterior wall of the left ventricle. Interestingly, the feeding vessels of the tumor were identified by echocardiography and coronary angiography. Histologically, the cardiac tumor was proven to be have the same pathologic findings as esophageal cancer, compatible with carcinomatous metastasis.

Minimally invasive esophagectomy

BACKGROUND

Open esophagectomy can be associated with significant morbidity and delay return to routine activities. Minimally invasive surgery may lower the morbidity of esophagectomy but only a few small series have been published.

METHODS

From August 1996 to September 1999, 77 patients underwent minimally invasive esophagectomy. Initially, esophagectomy was approached totally laparoscopically or with mini-thoracotomy; thoracoscopy subsequently replaced thoracotomy.

RESULTS

Indications included esophageal carcinoma (n = 54), Barrett's high-grade dysplasia or carcinoma in situ (n = 17), and benign miscellaneous (n = 6). There were 50 men and 27 women with an average age of 66 years (range 30 to 94 years). Median operative time was 7.5 hours (4.5 hours with > 20 case experience). Median intensive care unit stay was 1 day (range 0 to 60 days); median length of stay was 7 days (range 4 to 73 days) with no operative or hospital mortalities. There were four nonemergent conversions to open esophagectomy; major and minor complication rates were 27% and 55%, respectively.

CONCLUSIONS

Minimally invasive esophagectomy is technically feasible and safe in our center, which has extensive minimally invasive and open esophageal experience. Open surgery should remain the standard until future studies conclusively demonstrate advantages of minimally invasive approaches.

Minimally invasive surgical staging for esophageal cancer

BACKGROUND

The incidence of esophageal adenocarcinoma is increasing in the United States, and the 5-year survival rate is dismal. Preliminary data suggest that conventional imaging is inaccurate in staging esophageal cancer and could limit accurate assessment of new treatments. The objective of this study was to compare minimally invasive surgical staging (MIS) with conventional imaging for staging esophageal cancer.

METHODS

Patients with potentially resectable esophageal cancer were eligible. Staging by conventional methods used computed tomography (CT) scan of the chest and abdomen, and endoscopic ultrasound (EUS), whereas MIS used laparoscopy and videothoracoscopy. Conventional staging results were compared to those from MIS.

RESULTS

In 53 patients, the following stages were assigned by CT scan and EUS: carcinoma in situ (CIS; n = 1), I (n = 1), II (n = 23), III (n = 20), IV (n = 8). In 17 patients (32.1%), MIS demonstrated inaccuracies in the conventional imaging, reassigning a lower stage in 10 patients and a more advanced stage in 7 patients.

CONCLUSIONS

In 32.1% of patients with esophageal cancer, MIS changed the stage originally assigned by CT scan and EUS. Therefore, MIS should be applied to evaluate the accuracy of new noninvasive imaging methods and to assess new therapies for esophageal cancer.

Positron emission tomography of esophageal carcinoma using (11)C-choline and (18)F-fluorodeoxyglucose: a novel method of preoperative lymph node staging

BACKGROUND

Accurate preoperative staging is an important but difficult problem in determining therapy for patients with esophageal carcinoma. Positron emission tomography (PET) is used with [methyl-(11)C]choline ((11)C-choline) and 2-[(18)F]fluoro-2-deoxy-D-glucose ((18)F-FDG) to detect a variety of malignancies. The authors used PET with both of these agents to detect lymph node metastases in patients with esophageal carcinoma.

METHODS

Lymph node metastases in 33 patients with biopsy-proven esophageal carcinoma (16 patients with tumors classified as T1 and 17 patients with tumors classified as T2-4) was examined by PET using (11)C-choline and (18)F-FDG, and the accuracy of the results was correlated with pathology findings after surgery.

RESULTS

(11)C-choline PET was more effective than (18)F-FDG PET and computed tomography (CT) in detecting very small metastases localized in the mediastinum. It was ineffective, however, in detecting metastases localized in the upper abdomen, because of the normal uptake of (11)C-choline in the liver. (18)F-FDG PET was superior to CT in detecting metastases in the mediastinum and the upper abdomen, whereas (11)C-choline PET was superior to (18)F-FDG PET in detecting metastases in the mediastinum. When (11)C-choline PET and (18)F-FDG PET were used in combination, they were very effective in evaluating the lymph node status in both the mediastinum and the upper abdomen, and detected 85% of the metastatic lymph nodes (n = 46).

CONCLUSIONS

In this study, the combination of (11)C-choline PET and (18)F-FDG PET was very effective in evaluating the lymph node status of patients with esophageal carcinoma preoperatively.

Surgery, radiotherapy, and chemotherapy for esophageal cancer

Operative resection, the standard of care in the radical management of locoregional esophageal cancer, is a major surgical procedure, with a clear learning curve. It should be performed by experienced surgeons with a sufficient annual volume of procedures to maintain competence. Within specialized units esophagectomy can be safely offered to appropriately selected patients of all age groups. So far, the choice of operative approach (transhiatal, limited transthoracic, extended transthoracic) still cannot be based on randomized data with sufficient discriminating power. To date, the role of preoperative neoadjuvant therapy has not been clearly defined. A meta-analysis of five randomized trials did not confirm a substantial benefit for preoperative radiotherapy. A large randomized trial failed to show any benefit for preoperative chemotherapy. Improving systemic therapy, probably in combination with radiotherapy, remains a high priority for the coming years. The recent identification of new, highly active, chemotherapeutic agents shows promising, albeit preliminary, results.

Oesophagectomy for carcinoma of the oesophagus and oesophagogastric junction

OBJECTIVE

Oesophageal carcinoma has a poor prognosis; surgical resection remains the only chance of cure but is still associated with a significant morbidity and mortality. The aim of this study was to review the results of one surgeon for oesophageal resection for carcinoma of the oesophagus and oesophagogastric junction over a 23 year period.

METHODS

Between January 1974 and December 1996, 591 patients (408 males; 183 females; mean age 66 years) underwent an oesophageal resection for carcinoma of the oesophagus or oesophagogastric junction.

RESULTS

In hospital mortality was 8.8% (52/591). This has decreased to less than 5% for resections between 1985 and 1996. Non-fatal complications occurred in 21% of patients (123/591). Survival, including in hospital mortality (+/-SEM), was 53.98% (+/-2), 31.77% (+/-2) and 15.3% (+/-2) at 1, 2 and 5 years respectively.

CONCLUSION

Early mortality following oesophageal resection has fallen in recent years. Despite considerable experience, long term survival remains disappointingly low.