esophageal cancer approx. 13,000 cases/year in usa post-esophagectomy overall 5 yr survival = 18%...

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


• 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


• 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


• 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


• Anastomosis strategies:– Technique:

• Stapled (EEA)– Ease

– Strictures

• Sutured– single layer vs double layer, running vs interrupted


• 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”)


– 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


– 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)


– 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


– Conduit necrosis or large disruptions• Resect anastomosis, debride edges

• End cervical diverting esophagostomy

• Gastric remnant returned to abdomen

• Drainage

• Reconstruction in several months


• 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


• 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


• 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)


• 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


• 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


• 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


• 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


• 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


• 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


• 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 ?

esophageal cancer approx. 13,000 cases/year in usa post-esophagectomy overall 5 yr survival = 18%...

Documents

adeno ca slide

time of esophagectomy

useful slide

accuracy slide

esophageal cancer

wall penetration slide

nodes nodes

esophageal cas eval