Principles and Approaches in Surgical Resection of Esophageal Cancer

Abstract Background Esophageal cancer is the 8th most common cancer in the world. It is an lethal disease, responsible for almost 400.000 deaths by year. Surgical resection is considered the gold standard in esophageal cancer treatment, with a global 15–40% cure rate. In this study, the results of esophageal cancer surgical treatment at Brazilian National Cancer Institute, Abdominal-pelvic Surgical Section, is analyzed. Methods The medical records of 215 patients with esophageal cancer, treated with surgical resection (esophagectomy), between January 1999 and December 2015, were retrospectively studied. The endpoints analyzed in the study were: hospitalization time, operative complications and mortality, and overall survival. Results Esophageal cancer was predominant in male patients; median age was 58 years (27–78). Primary tumor location varied between 7,5 - 41 cm (median 32cm) and tumor extension 1 - 16cm (median 5cm). Median surgical time was 330 minutes (120–720); transhiatal esophagectomy with gastric tube reconstruction was the most used surgical approach. Tumors histopathological types were equaly distributed. ICU (Intensive Care Unit) stay median time was 5 days (1–87) and median hospitalization time was 15 days (5–166). Most common surgical complications were anastomotic leakage (25,5%) and pneumonia (20%), with a surgical morbidity rate of 61,8%. Surgical mortality rate was 12%, with 61% of these cases occuring in the 30 days after surgery. Median 2-year overall survival was 44,3 months. Conclusion Besides the high surgical morbidity, esophagectomy for esophageal cancer remains the standard treatment for patients with ressectable tumors and without clinical contraindications for surgery. Reduction of surgical mortality depends on rigorous patients selection, surgical team expertise and adequate perioperative and postoperative care. Disclosure All authors have declared no conflicts of interest.

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Comparison of endoscopic therapies and surgical resection in patients with early esophageal cancer: a population-based study

Gastrointestinal Endoscopy ◽

10.1016/j.gie.2013.08.002 ◽

2014 ◽

Vol 79 (2) ◽

pp. 224-232.e1 ◽

Cited By ~ 61

Author(s):

Sachin Wani ◽

Jennifer Drahos ◽

Michael B. Cook ◽

Amit Rastogi ◽

Ajay Bansal ◽

...

Keyword(s):

Esophageal Cancer ◽

Surgical Resection ◽

Population Based ◽

Early Esophageal Cancer ◽

Population Based Study

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Endoscopic submucosal dissection of high grade intraepithelial neoplasia of the head and neck in a patient after surgical resection of esophageal cancer

Endoscopy ◽

10.1055/s-0034-1365429 ◽

2015 ◽

Vol 47 (S 01) ◽

pp. E49-E50

Author(s):

Yu-qi He ◽

Ai-qin Li ◽

Xin Wang ◽

Kuang-I Fu ◽

Jian-qiu Sheng

Keyword(s):

Esophageal Cancer ◽

Endoscopic Submucosal Dissection ◽

Head And Neck ◽

Surgical Resection ◽

Intraepithelial Neoplasia ◽

High Grade ◽

Submucosal Dissection

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Room for improvement? The adoption of multimodal esophageal cancer care in the United States.

Journal of Clinical Oncology ◽

10.1200/jco.2011.29.4_suppl.78 ◽

2011 ◽

Vol 29 (4_suppl) ◽

pp. 78-78

Author(s):

R. P. Merkow ◽

K. Y. Bilimoria ◽

M. McCarter ◽

A. Stewart ◽

W. B. Chow ◽

...

Keyword(s):

Esophageal Cancer ◽

Neoadjuvant Therapy ◽

Surgical Resection ◽

Tumor Size ◽

Locally Advanced ◽

The United States ◽

Stage I ◽

Stage Ii ◽

Cancer Data ◽

Factors Associated

78 Background: Consensus guidelines recommend neoadjuvant chemo- or chemoradiation therapy as the preferred treatment for locally advanced esophageal adenocarcinoma; however, it is unknown if this recommendation has been widely adopted in the U.S. Our objective was to examine esophageal cancer multimodal therapy and identify factors associated with the use of neoadjuvant therapy. Methods: From the National Cancer Data Base, patients with middle third, lower third and GE junction (GEJ) adenocarcinomas were identified. Patients who were clinical stage I-III and underwent surgical resection were included. Separate logistic regression models were developed to identify predictors of neoadjuvant therapy utilization and outcomes. Results: From 1998 to 2007, 8,051 patients underwent surgical resection for esophageal cancer: 16.3% stage I, 45.0% stage II and 38.7% stage III. For stage II/III tumors, neoadjuvant use increased (49.0% to 77.8%, p<0.001). After adjustment, factors associated with underuse of neoadjuvant therapy in stage II/III patients were older age, Black or Hispanic ethnicity, more severe comorbidities, tumor location (GEJ and middle vs. lower third), tumor size ≥ 2cm, stage II (vs. III) and geographic region. Stage II/III patients not receiving neoadjuvant had an over two fold increased risk of positive lymph nodes (OR 2.14. 95% CI 1.79 – 2.55, p<0.001). In addition, the positive surgical margin rate increased almost three fold (OR 2.80 95% CI 2.17-3.62, p<0.001) but 30-day postoperative mortality risk was not significantly affected (OR 1.50 95% CI 0.94-2.39; p=0.090). For stage I patients, neoadjuvant therapy decreased over time (38.0% to 11.4%, p<0.001). The overuse of neoadjuvant therapy was associated with higher tumor grade, larger tumor size, and low surgical case volume (all p<0.05). Conclusions: The adoption of neoadjuvant therapy has increased in the past decade; however, opportunity exists to improve guideline treatment for locally advanced esophageal cancer. Registry-based feedback to individual hospitals, such as benchmark comparison tools, could help institutions provide care in concordance with national guidelines. No significant financial relationships to disclose.

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Survival in patients with esophageal cancer treated with surgery after chemoradiotherapy.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.4_suppl.98 ◽

2013 ◽

Vol 31 (4_suppl) ◽

pp. 98-98

Author(s):

Ravi Shridhar ◽

Jessica Freilich ◽

Sarah Hoffe ◽

William J. Fulp ◽

Michael Chuong ◽

...

Keyword(s):

Esophageal Cancer ◽

Radiation Dose ◽

Surgical Resection ◽

Randomized Trials ◽

Tumor Location ◽

Tumor Length ◽

Lower Stage ◽

Radiation Technique ◽

Nonsurgical Patients

98 Background: Chemoradiotherapy (CRT) followed by surgical resection is the standard of care for treating advanced esophageal cancer. However, the role of surgery has come into question in recent studies. The purpose of this study is to compare outcomes of patients treated with CRT with or without surgery. Methods: An IRB-approved database was queried to identify esophageal cancer patients treated with CRT with or without surgical resection between 2000 and 2011. Overall survival (OS) and disease-free survival (DFS) were calculated by the Kaplan-Meier method and log-rank analysis. Multivariate analysis for OS and DFS were calculated with a Cox proportional hazard ratio model. Results: We identified 232 patients treated with CRT (122 without surgery, 110 with surgery). Surgery was associated with a significant increase in OS and DFS. Median and 5 year OS for surgical versus nonsurgical patients was 42.2 months, and 42.3% versus 20.4 months and 29%, respectively (p = 0.0003). Median and 5 year DFS for surgical versus nonsurgical patients was 16.8 months and 29% versus 8.4 months and 22.8% (p < 0.001). MVA for OS revealed that lower stage (p = 0.0098), tumor length <5 cm (p = 0.0059), and surgery (p<0.0001) were prognostic for significantly decreased mortality, while age, gender, histology, tumor location, radiation dose, and radiation technique were not prognostic. MVA for DFS showed that tumor length <5 cm (p = 0.0112), radiation technique (p = 0.0023), and surgery (p = 0.0007) were prognostic for significantly decrease mortality, while lower stage (p = 0.069) and squamous histology (p = 0.055) were trending for decreased mortality. Age, gender, radiation dose, and tumor location were not prognostic for DFS. Conclusions: Surgery after CRT is strongly associated with increased OS and DFS in our esophageal cancer patient population. While we highly recommend surgical resection as part of trimodality treatment, it should only be performed in high volume centers. Longer followup in the already conducted randomized trials involving squamous cell carcinomas are needed to better qualify the initial negative results and randomized trials are need to address the role of surgery for adenocarcinomas.

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Survival outcomes comparable between endoscopic resection and surgical resection for T1b esophageal adenocarcinoma.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.4_suppl.100 ◽

2019 ◽

Vol 37 (4_suppl) ◽

pp. 100-100

Author(s):

Samit Kumar Datta ◽

Geoffrey Belini ◽

Maharaj Singh ◽

Wesley Allan Papenfuss ◽

Lyndon Hernandez ◽

...

Keyword(s):

Esophageal Cancer ◽

Surgical Resection ◽

Endoscopic Resection ◽

Charlson Comorbidity Index ◽

National Database ◽

Mortality Data ◽

Survival Outcomes ◽

Cancer Data ◽

Comorbidity Index ◽

Large National Database

100 Background: Current guidelines recommend esophagectomy for submucosal T1b esophageal cancer. Data regarding efficacy of endoscopic resection (ER) of T1b esophageal cancer are limited. Our goal was to compare survival outcomes of ER as opposed to conventional surgical resection (SR) in a large cohort of patients with T1b cancers from a large national database. Methods: Data were obtained from the large national database maintained by the Commission on Cancer. Patients with T1b esophageal cancers with clinical stage 1A and 1B who underwent ER and SR between 2010 and 2014 were identified using the American Joint Committee on Cancer (AJCC Version 7). Patients undergoing ER and SR were identified. Patients who underwent neoadjuvant therapy or had incomplete survival data were excluded. The primary outcome was survival for age and Deyo-Charlson comorbidity index. We also evaluated 30-Day and 90-Day Mortality outcomes. Results: There were 1071 patients with T1b esophageal cancer with complete mortality data. After selecting and excluding patients above, 141 patients were identified who underwent EET and 286 who underwent esophagectomy. Average age was 71.5 years in the ER group and 64.5 years in the SR group (p < 0.001). In the group, 30-Day mortality after surgery was 1/134 (0.8%, 7 missing) compared to surgery with 30-Day mortality of 6/283 (2.1%, 3 missing) (P = 0.308). 90-Day mortality after surgery for the ER group was 3/134 (2.2%, 7 missing) compared with the surgery with 90-Day mortality of 11/281 (3.9%, 5 missing) (P = 0.377). Adjusted for age and Deyo-Charlson comorbidity index, there was a HR of 1.051 (95% CI 0.695-1.589, p = 0.815) for mortality associated with surgery compared with ER. Mean follow-up of 42.6 months for the ER group and 55.7 months for surgery group. Conclusions: Based on the data from a large national cancer data base ER seems to be comparable to SR in terms of short term (30 day and 90 day) mortality. Overall survival seems to be similar in both groups Prospectively done randomized studies comparing ER versus SR are desirable.

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