c l i n i c a l
f o l i o s :
d i s c u s s i o n
Esophageal Carcinoma
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Esophageal Carcinoma | ||
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Related narratives: Ivor-Lewis Esophagectomy, Transhiatal Esophagectomy Esophageal carcinoma is the seventh leading cause of cancer death worldwide. Although less common in the United States than endemic areas, its incidence is rising, representing 5.5% of all neoplasms of the gastrointestinal tract and 1% of all cancers (1). Squamous cell carcinoma predominates in endemic areas, however, the incidence of adenocarcinoma has risen in the United States and is now more common. The predominant risk factors in western culture have been identified as Barrett's esophagus (adenocarcinoma), and heavy consumption of tobacco and alcohol products (squamous carcinoma). Because of its insidious nature, esophageal carcinoma is usually not diagnosed until it has progressed to advanced stage. Though often a late finding, the most common presenting symptom is dysphagia, ( 80-90%). Anorxia and weight loss are also frequently present (2). Adequate clinical staging is mandatory to plan appropriate therapy. Endoscopic ultrasound has evolved as the test of choice for precise determination of tumor penetration and nodal status. CT scanning can be helpful to further delineate the anatomic relationship of the tumor to surrounding structures, and also to assess for possible distant metastasis. Additionally, bronchoscopy is advisable when the tumor is located in the middle of the esophagus to identify airway invasion, generally found at the level of the left mainstem bronchus (see tracheobronchial relationships). Though long term survivability remains poor, surgical resection remains the mainstay of therapy for patients with potentially resectable esophageal cancers. Numerous studies have evaluated the efficacy of adjuvant and neoadjuvant strategies utilizing radiation, chemotherapy and combined chemoradiotherapy. Overall, these strategies are considered controversial. However, studies have demonstrated survival benefit using neoadjuvant chemoradiotherapy in some patients with adenocarcinoma of the esophagus. Primary radiotherapy may produce excellent, but usually short lived response rates in persons with squamous cell carcinoma.(3) Complete tumor resection (R0) should be the goal of curative surgery for esophageal malignancy. This often requires margins of apparently normal esophagus given the diffuse submucosal growth pattern of esophageal cancers. Most favored surgical approaches in the United States are the transhiatal or "blunt" esophagectomy championed by Orringer, and the Ivor-Lewis esophagectomy perfomed through separate abdominal and right thoracotomy incisions as shown in the clincal vignette above. The choice of procedure is tailored to the specific presentation of the patient and to both the patient's and surgeon's preference. The most compelling advantage of the transhiatal approach is the cervical anastamosis, avoiding a potentially lethal intrathoracic anastamotic leak, and the avoidance of a painful thoracotomy with its attendant pulmonary complications. The potential benefits of the Ivor-Lewis approach include the safety of dissection under direct vision (perhaps most relevant for tumors of the mid esophagus) and the abiltiy to perform more comprehensive lymphadenectomy. No survival benefit has been demonstrated for one approach over the other. The patient above underwent Ivor-Lewis resection because of tumor location and surgeon preference. Non-operative strategies for patients in whom resection is not felt to be feasible or desirable include primary chemoradiation and primary radiotherapy for squamous cell carcinoma. Palliative options for patients with widespread or unresectable, locally advanced disease include the use of esophageal stents, laser tumor ablation, endoscopic resection, photodynamic therapy alone, or in combination with chemotherapy and radiotherapy (4). References: 1. Fleming, I, Cooper, J et al. Editors, AJCC Cancer Staging Manual, Fifth Edition, Lippincot Williams and Wilkins, 1998. 2. Lee, R. and Miller, J, Esophagectomy for cancer, Surgical Clinics of North America. Vol 77, #5, Oct 1997. 3. Stein, H, Sendler, A, et al., Multidisciplinary approach to esophageal and gastric cancer, Surgical Clinics of North America, Vol 80, #2, April 2000. 4. Ponee, R, Kimmey, M., Endoscopic therapy of esophageal cancer, Surgical Clinics of North America, Vol 77, #5, Oct 1997.
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