esophageal cancer approx. 13,000 cases/year in usa post-esophagectomy overall 5 yr survival = 18%...
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Esophageal Cancer
• Approx. 13,000 cases/year in USA• Post-esophagectomy overall 5 yr survival = 18%
– At presentation, 57% patients are Stage 3, with a 10% post-esophagectomy surv.
– At presentation, 24% patients are Stage 2, with a 35% post-esophagectomy surv.
– At presentation, patients who are Stage 1, have an 80% post-esophagectomy surv.
Esophageal CA -- pre-op staging
• TNM staging somewhat overbroad– If T1, but tumor is in mucosa only:
• Lymph node metastases < 10%
– If T1, but tumor extends into submucosa:• Lymph node metastases = approx. 30
• Distant mets, lymph nodes, wall penetration
Esophageal CA -- find distant mets
• Distant mets– CT chest and abdomen -- mostly useful in trying
to detect distant mets– but, CT chest and abdomen -- only 60% accurate
in detecting regional lymph node disease– but, CT chest and abdomen -- underestimates
tumor stage in 40% of patients– Addition of PET may improve accuracy
Esophageal CA -- find distant mets
• Distant mets– Bronchoscopy in proximal and middle third
esophageal CA’s• eval. for posterior tracheal invasion
– “slight compression” still resectable
– “abnormal tracheal mucosa” unresectable
Esophageal CA -- eval. lymph nodes
• Lymph node status– Thoracoscopic staging can find LNs, but poorly
predicts unresectability– Laparoscopic staging can change treatment in
30% of distal esophageal Cas• Matted celiac nodes
• Carcinomatosis
• Small liver lesions
Esophageal CA -- eval. lymph nodes
• Lymph node status– Laparascopic staging
• Laparscopic ultrasound of liver not useful
Esophageal CA -- pre-op staging
• Wall penetration– Endoscopic ultrasound -- incorrect in
determining wall depth 15-20% of the time– Endoscopic ultrasound -- incorrect in
determining nodal status 25 - 30% of the time– Endoscopic ultrasound -- less accurate after
neoadjuvant therapy
Esophageal CA -- pre-op staging
• Wall penetration– “High grade dysplasia” = 43% occult adeno CA– Tumor limited to submucosa --> 19% LN
involvement• 3% had more than 4 nodes
• Nodes limited to peri-esophageal, not spleen or peri-gastric => no need to resect these
– Invasion of muscularis propria --> 80% LN involvement
Esophageal CA -- chemoradiation
• Treatment of choice for Stage 4 (mets)– Stent esophageal lesion, chemo and radiation
• SCC responds to radiation better than Adeno CA
Esophagectomy -- Types of operations
• Incision strategies:– Ivor-Lewis
• Laparotomy, thoracotomy
– Transhiatal
• Conduit strategies:– Gastric pull-up– Colonic interposition– Jejunal interposition
Esophagectomy -- Types of operations
• Anastomosis strategies:– Location:
• Cervical
• Intrathoracic – Anastomotic technique does not affect leak rate
– Radiation, vascular supply does
• Post-op feeding strategies:– Jejunosotmy feeding tube placed at time of
esophagectomy
Esophagectomy -- Types of operations
• Anastomosis strategies:– Technique:
• Stapled (EEA)– Ease
– Strictures
• Sutured– single layer vs double layer, running vs interrupted
Esophagectomy -- Types of operations
• Anastomosis strategies:– Tension issues
• Tacking sutures not often used in stapled anastomoses
• Gastric emptying strategies– 15% pyloric obstruction rate– Pyloroplasty, pyloromyotomy ?
• +/- Graham patch
• Vagotomy
Esophagectomy -- Intra-operative complications
• Bleeding– average < 800 cc for Ivor-Lewis
– transhiatal esophagectomy bleeding• left thoracoabdominal extension vs. left thoractomy
• Aortic a., bronchial a., azygous v. bleeding --> pack, then upper sternal split
• Tracheobronchial injury– secure airway by advancing ETT, then repair
• primarily vs. pedicled flap buttress
Esophagectomy -- Intra-operative complications
• Recurrent laryngeal nerve injury– especially in cervical dissections
Esophagectomy -- Operation by stage
• Barrett’s esophagus with High-grade dysplasia or intramucosal adeno-CA– No visible tumor on endoscopic U/S
• but again, U/S may not be accurate in distinguishing mucosal vs. submucosal confinement
– Vagal sparing esophagectomy, transhiatal esophagectomy
• If no regional disease detected
Esophagectomy -- Operation by stage
• Barrett’s esophagus with High-grade dysplasia or intramucosal adeno-CA– No visible tumor on endoscopic U/S
• but again, U/S may not be accurate in distinguishing mucosal vs. submucosal confinement
– Investigational: Mucosal ablation (laser, photodynamic), endoscopic mucosal resection
Esophagectomy -- Operation by Stage• Tumor confined to submucosa on U/S
– Visible tumor on endoscopic U/S• 75% have tumor past mucosa into submucosa and beyond when
seen on U/S
• 56% have lymph node metastases (both limited to and extending past submucosa)
– Extended transhiatal esophagectomy
– Complete lower mediastinal and upper abdominal lymph node resection
• since only 19% had LNs if limited to submucosa
• not “en bloc” since only 3% had > 4 LNs
Esophagectomy -- Operation by Stage
• Tumor into or through muscularis propria– 75% to 85% LN involvement– 45% have > 4 LNs– 30 - 40% have distant LNs involved (25% celiac LNs)
– radical en bloc esophagectomy (DeMeester)• 1-5 % local recurrence rate
– however, most surgeons do not perform radical en bloc resections, relying on adjuvant therapy
• 35% local recurrence operation alone (i.e. not “en bloc”)
Esophagectomy -- Operation by Stage
– Radical en bloc esophagectomy (DeMeester)• 1-5 % local recurrence rate
– Compare 35% local recurrence overall after esophagectomy
• Five-year survival for Stage 3 is 23 - 50%– Compare overall five-year Stage 3 post-esophagectomy
survival rate of 10%
– Cervical lymph node dissection• Mid-thoracic tumors and upper third tumors have
45% cervical lymph node mets
Esophagectomy -- Operation by Stage
– Cervical lymph node dissection• Mid-thoracic tumors and upper third tumors have
45% cervical lymph node mets
• No survival advantage to cervical LN resection (Nishimaki, 1999)
– Exception was 1 to 4 LNs (but how can you tell in advance?)
• Significant additonal morbidity (80%) with additional lymph node (“three-field”) dissection
Esophagectomy -- Complications
• Mortality 3 - 5%, Morbidity 15-18%
• Anastomotic leaks -- 1 - 5%– Cervical
• leak rate 0-12%, post-op day 5-10
• fever, crepitance, drainage, erythema, leukocytosis
• requires wide incision and drainage, not repair
• 1/3 develop stricture --> I&D (not repair)
Esophagectomy -- Complications
– Thoracic --> Gastrograffin swallow vs. CT• With-hold feeding additional 5-7 days if < 1 cm
contained leak– Repeat esophagogram
• Exploration if free leak or > 1 cm contained leak (risk of erosion by mass effect)
• Pediatric endoscope at exploration time (?)
• Assess for large disruptions or necrosis of conduit
Esophagectomy -- Complications
– Conduit necrosis or large disruptions• Resect anastomosis, debride edges
• End cervical diverting esophagostomy
• Gastric remnant returned to abdomen
• Drainage
• Reconstruction in several months
Esophagectomy -- Complications
• Conduit obstruction at diaphragm– Two fingers width alongside conduit at diaphragm
– Resect head of left clavicle, first rib, manubrium in cervical anastomoses as needed
• Diaphragmatic bowel herniation– Prevent by suturing conduit to hiatus with 3 - 4 sutures
– Vague lower thoracic/upper abd. cramping pains
– CXR; CT or contrast study if in doubt
– Repair with hiatal closure and anchoring sutures
Esophagectomy -- Complications
• Chylothorax– 1 - 3%
– Ligate intraoperatively when identified
– Massive (800 cc/day) chest tube output at 5 - 7 days post-op vs. tension chylothorax if no Chest Tube
– Feed cream -- note change in chest tube character
– Stop enteral feeds; start TPN
– Explore promptly and ligate thoracic duct through right thoracotomy, VATS, or prior thoracotomy
Esophagectomy -- Complications
• Anastomotic strictures -- 5 - 42%– More often if lye, leak, small EEA staplers, suture technique,
irradiation
– Requires dilatation (80% dilatation success)• Early after leak• Combined with endoscopy• Use 46 Fr or larger Maloney dilators, balloons when necessary• Repeat until 6 months of stability• use extra care if colon, small bowel conduit
– Chronic (> 12 mo) cervical anastomotic strictures• Stricturoplasty / SCM flap (50% failure) / Lat. Dorsi flap / free radial
arm flap / pectoralis myocutaneous flap (like ENT flaps)
Esophagectomy -- Complications
• Delayed hemorrhage (rare)– Consider splenic injury
• Aspiration pneumonia -- 3%– Videoesophagogram before re-feeding 5-7 days
• Dysphagia
• Regurgitation
• Delayed emptying– Only 15% develop pyloric obstruction
– Balloon dilatation, erythromycin, metoclopramide
• Dumping
Esophagectomy -- Post-op diet
• Smaller, more frequent meals
• Drink liquids after meals to avoid gastric distension
• Avoid high carbohydrate diets
• Liberal anti-diarrheal use– Dumping symptoms usually resolve in 6 - 12
months
Esophageal CA -- radiation
• 20 to 40 Gy over 2 - 4 weeks (1.75 to 3.75 Gy/fx)• Squamous cell carcinoma -- more radiosensitive• Preoperative radiation versus surgery alone
– no improved survival in long-term randomized trials
• Post-op radiation versus surgery alone– no improved survival, but higher stricture rate– improved local recurrence rates in node negative
mid- to upper-third SCCs
Esophageal CA -- chemo
• Pre-operative chemo (Cisplatin, 5-FU)– Only 19% response– No change in survival– No change in local recurrence rates or patterns
Esophageal CA -- chemoradiation
• Pre-op chemoradiation (cisplatin/5-FU)– 40% (histologic) response rate (average)
• Similar response rates for SCC and AdenoCA• Response rate dependent on time to surgery following
chemoradiation
• What is ideal delay to surgery?– In rectal CA, 6-8 week gap allows more restorative surgery than
does a 2 week gap– Allow healing ability to recover– Allow clinical tumor shrinkage
Esophageal CA -- chemoradiation
• Pre-op chemoradiation (cisplatin/5-FU)– Increases surgical M/M by 5-15%
• With high does rad’n (high dose (3.5 Gy) /fraction (TE fistula)
• Anastomotic leaks, strictures
• Toxicities – myelotoxicity if Mitomycin C, etoposide, vinblastine
added
• Average results, not controlled by delay to surgery
Esophageal CA -- chemoradiation
• Pre-op chemoradiation (cisplatin/5-FU) – Non-significant improvements yet seen
• Urba(2001, AdenoCA only) : 3 year survival 16% --> 30% (P=0.15)
– Local recurrence 41% --> 19%
• Clark(2000abstract) : 2 year 35% --> 45% (P=.002)– median survival difference 4 months, short F/U
• Walsh (1996, adenoCA only) : highly controversial: 6% --> 32%
• Bossett(1997, Stage 1 and 2 SCC only): no difference
Esophageal CA -- chemoradiation
• Pre-op chemoradiation (cisplatin/5-FU) – Survival differences may be lost by 5 years– Benefits not yet substantiated by long-term
studies (2002 review)
Esophageal CA -- chemoradiation alone
• Chemoradiation instead of surgery– Studies show pathologic and clinical response
rates comparable to historical esophagectomy survivals in Stage 2 and 3 carcinomas
• EORTC trial in progress -- 30 Gy with 5 FU/Cisplatin
– Comparisons are not against “en bloc” resections
Esophageal CA -- chemoradiation alone
• Chemoradiation (CRT) instead of surgery– 40-60% of CRT alone die with local recurrence/failure
• Compare 9% with CRT plus surgery
• Surgical salvage following CRT alone– no difference in salvage versus CRT alone
Esophageal CA -- chemoradiation alone
• Chemoradiation instead of surgery– Current methods to determine complete (clinical)
response are inadequate to predict which patients might not require surgery in addition to chemoradiation
• Endoscopic U/S or MRI -- accuracy inadequate in determining local and regional tumor
• PET, CT -- can’t detect regional nodes well
• Histologic response -- not avail. without resection
• Future: biologic serum markers ?
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