Selection of Operation for Esophageal Cancer Based on Staging
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Abstract:
The concept of en bloc removal of tissue surrounding the esophagus was applied to intrathoracic esophageal cancers, and the first 80 cases were operated on by this technique between 1969 and 1981. Analysis of prognostic factors showed that only penetration through the esophageal wall and lymph node spread influenced survival. Since 1981, a new staging system based on wall penetration (W) and lymph nodes (N), as well as systemic metastases (M), and similar to the modified Dukes' system for colon cancer has been used to select patients before and during surgery for en bloc resection if favorable pathology (W1, N0, or N1) could be anticipated. When curative resection was not attainable, based on preoperative and operative staging, a standard esophagectomy was considered for relief of symptoms when necessary. From July 1981 to June 1984, 68 esophageal cancers were referred to us, and 31 were resected by the en bloc method, 21 by standard esophagectomy, and 16 were not resected. The success of preoperative staging was confirmed, as only nine of the 31 en bloc cases demonstrated both W2 and N2 pathology. The proportion of W2N2 cases subjected to en bloc esophagectomy was less (p < 0.01) than that in the preceding series. This selection of cases showed a favorable deviation in the survival curve following en bloc esophagectomy since 1981 compared to the earlier interval. Patients treated by en bloc esophagectomy had a significantly greater survival than they did following standard esophagectomy at all time intervals after 6 months. There was no difference in hospital mortality or complications between the two operations. Further evidence for the value of the new staging system was shown by the significant difference in survival curves between those with favorable versus unfavorable staging and treated by en bloc esophagectomy. Among all cases resected between 1981 and 1984, 18-month survival in W1 stage was 67% compared to 35% for W2 disease. Survival with NO disease was 58% versus 43% for N1 stage and 21% for N2 stage. The favorable survival rates after en bloc resection in those with limited (< W2N2) disease support the concept of selecting patients for curative surgery based on preoperative and operative staging. Preoperative radiation therapy caused a significant decline in patient survival at 6 and 12 months and has been abandoned. Adjuvant postoperative irradiation and/or chemotherapy was offered to all patients with W2, N1, N2, or M1 pathology and was accepted by approximately two thirds. There was no difference in the survival curves between those who did and did not accept postoperative therapy. However, in the patients with W2N2 disease, survival between 9 and 15 months was prolonged by approximately 6 months in those receiving postoperative treatment, and the difference approached statistical significance (0.1 > p > 0.5). Staging for esophageal cancer based on wall penetration and lymph node spread is valuable in determining prognosis and selection of treatment. For those with favorable staging, the use of en bloc resection for attempted cure has an acceptable mortality and an improved survival rate compared to those with the same stage disease treated by standard esophagectomy. En bloc resection appears particularly worthwhile in those with limited spread from the primary (W1N1 and W2N0). For those whose staging indicates little hope for prolonged survival, resection may be used for palliation of dysphagia and bleeding. Adjuvant therapy is still not a proven benefit, but trials should continue in patients with unfavorable disease.Keywords:
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Esophagectomy
Chemoradiotherapy
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Objective To compare the long-term prognosis effects of non-esophagectomy and esophagectomy on patients with T1 stage esophageal cancer. Methods All esophageal cancer patients in the study were included from the National Surveillance Epidemiology and End Results (SEER) database between 2005-2015. These patients were classified into non-esophagectomy group and esophagectomy group according to therapy methods and were compared in terms of esophagus cancer specific survival (ECSS) and overall survival (OS) rates. Results A total of 591 patients with T1 stage esophageal cancer were enrolled in this study, including 212 non-esophagectomy patients and 111 esophagectomy patients in the T1a subgroup and 37 non-esophagectomy patients and 140 esophagectomy patients in the T1b subgroup. In all T1 stage esophageal cancer patients, there was no difference in the effect of non-esophagectomy and esophagectomy on postoperative OS, but postoperative ECSS in patients treated with non-esophagectomy was significantly better than those treated with esophagectomy. Cox proportional hazards regression model analysis showed that the risk factors affecting ECSS included race, primary site, tumor size, grade, and AJCC stage but factors affecting OS only include tumor size, grade, and AJCC stage in T1 stage patients. In the subgroup analysis, there was no difference in either ECSS or OS between the non-esophagectomy group and the esophagectomy group in T1a patients. However, in T1b patients, the OS after esophagectomy was considerably better than that of non-esophagectomy. Conclusions Non-esophagectomy, including a variety of non-invasive procedures, is a safe and available option for patients with T1a stage esophageal cancer. For some T1b esophageal cancer patients, esophagectomy cannot be replaced at present due to its diagnostic and therapeutic effect on lymph node metastasis.
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Postoperative complications, especially pulmonary complications, affect more than half the patients who undergo open esophagectomy for esophageal cancer. Whether hybrid minimally invasive esophagectomy results in lower morbidity than open esophagectomy is unclear.
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Since mucosal (T1a) esophageal cancer is well controlled by endoscopic treatment, chemoradiotherapy (CRTx) is not indicated. However, for a submucosal (T1b, N0) esophageal cancer, CRTx may be the first line of treatment, since it can provide a good response rate, with an excellent survival rate comparable to that after esophagectomy. Definitive CRTx is also in the first line of treatment for a T4 esophageal cancer, because there was no difference in the survival rate between CRTx with surgery and CRTx without surgery in our trial. Esophagectomy is indicated only for non-responders or recurrence-salvage surgery. For patients with a potentially-resectable (T2-T3) esophageal cancer, esophagectomy offered a longer survival rate than CRTx did, in our series. However, there remains controversy over the efficacy of CRTx for a T2-T3 esophageal cancer. It has been reported by the National Cancer Center Hospital East Group that definitive CRTx provided the same survival rate as esophagectomy. A prospective trial comparing the survival rate after esophagectomy and that after CRTx for a T2-T3 esophageal cancer is needed.
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Background: Esophagectomy offers the chance of cure for esophageal cancer, however, the optimal circumferential extent of surgery remains uncertain. En bloc esophagectomy (EBE) and total meso-esophagectomy (TME) have yielded inconsistent results. Therefore, the purpose of this study was to evaluate the surgical and oncological effects of EBE and TME on esophageal cancer patients.
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We report 2 cases of small cell carcinoma of the esophagus treated with esophagectomy as a primary treatment and following chemotherapy. One patient (pT1N1M0) achieved long-term survival, while the other patient (pT1N1M1-lym) died 18 months after surgery. We used reports on 47 Japanese patients receiving esophagectomy as a primary treatment to determine when esophagectomy for small cell carcinoma of the esophagus is indicated. We conclude that esophagectomy as a local treatment provides relatively good long-term survival only in patients without lymph node involvement.
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Definitive chemoradiotherapy has been demonstrated to offer a chance of cure for esophageal cancer as often as a radical esophagectomy. However, it is generally accepted that an esophagectomy remains the mainstay of treatment for patients with resectable esophageal cancer, while chemoradiotherapy is the standard for patients with medically inoperable or surgically unresectable esophageal cancer. The mortality rates and the 5-year survival rates after an esophagectomy were 29% and 4%, respectively, in an early extensive reviews involving 122 English papers on esophageal cancer surgery published between 1960 and 1979. The respective rates have improved to 6.7% and 27.9% in the most recent systematic reviews involving 312 papers published between 1990 and 2000. The overall survival at 5 years was 36.1% after esophagectomy in 11,642 patients between 1988 and 1997 in Japan. A 3-field lymphadenectomy involving the 3 anatomical compartments of the neck, mediastinum, and abdomen was introduced as an important component of a curative esophageal resection in the early 1980s in Japan, and has been reported to be effective for improving not only the staging accuracy, but also the long-term survival in patients with esophageal cancer, with the average 5-year survival rate being 40 to 60%. At present, 63% of all Japanese patients with esophageal cancer undergo an esophagectomy. Of these patients undergoing surgery, a 3-field and a conventional 2-field lymphadenectomy is performed in 35% and 33%, respectively. Alternatively, a transhiatal esophagectomy without a systematic lymphadenectomy has become one of the preferred types of surgery for patients with esophageal cancer in Western countries. An Appropriate Esophagectomy for Esophageal Cancer: A Lack of Evidence and a Growing Disparity between Western and Eastern Standards
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