evolution of surgical management of carcinoma esophagus

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Carcinoma
Esophagus - Surgical
trials

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• The main goal of surgery in esophageal
cancer was good palliation and the cure is
an accident.
- Ronald H. Belsey (1910-2007)

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History
• First excision of Esophagus is done by
Christian Albert Theodor Billroth, an
Austrian surgeon -1872
• Vincenz Czerny (1842-1916) performed the
first successful human resection of cervical
Esophagus in 1877 where he had resected
a carcinoma of cervical Esophagus that
provided patient a one year survival.

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• A Major pioneer in esophageal surgery was
Ivor Lewis (1895 to 1982) who in 1946 made a
substantial advancements with the
introduction of esophagectomy and
esophagogastrostomy
• Surgery has normally been considers the only
option for patients with early stage cancer of
Esophagus until the mid 1980s, later that
other combined modality options became
available to patients

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Treatment of Premalignant Disease
• Photodynamic laser
• Multipolar Electro coagulation
• argon plasma coagulation
• Cryotherapy
• Radio frequency ablation

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• A RCT of 127 Overall,
• 77.4% of patients in the ablation group had
complete eradication of intestinal metaplasia, as
compared with 2.3% of those in the ( PLACEBO)
control group (P<0.001).
• Patients in the ablation group had less disease
progression (3.6% vs. 16.3%, P=0.03) and fewer
cancers (1.2% vs. 9.3%, P=0.045).

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Chance of lymphnode involvement
• m1 and m2 is 0%
• m3 8%
• sm1 17% ( <200 micro meter thickness)
• sm2 30%

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Endoscopic resection
SIZE < 2cm
Not poorly differentiated
No Nodal involvement
Lesion thickness not beyond sm1

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EMR or ESD for superficial
esophageal cancer
• EMR for lesions < 2cm/ ESD for >2cm
• Pooled R0 resection rate – 90%
• If tumor > 2.5cms – R0 resection rate is 85%
• 5 year recurrence rate – EMR (23%) vs ESD (2.9%)

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•If the disease is extensive, or
pT1b(sm2,sm3) esophagectomy is
recommended

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NCCN Guidelines
• Esophagectomy is recommended primary
treatment option for patients with pT1b,N0
tumours and cT2,N0 low risk lesions (
<3cm in diameter and well- differentiated)

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NCCN guidelines
• Preoperative Chemoradiation ( for
Non cervical Esophagus) and
definitive Chemoradiation ( for
cervical Esophagus) are recommended
for patients with cT2,N0 high risk
lesions ( LVI, >3cm, poorly
differentiated) and cT1b-cT2, N+ or
cT3-cT4a, any N tumours

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Transhiatal Esophagectomy
• En-bloc resection is feasible for distal esophageal
tumors
• Laparotomy and cervical approach
• Peritumoral or two field lymph node dissection (
Abdominal and lower mediastinal)
• Cervical anastomosis

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• N – 1525 patients
• 79% of them had Adeno carcinoma
• Tumors located in lower third Esophagus in 82%,
middle and upper third in 18%
• In hospital mortality was 3%
• Most common complication was anastomotic leak
(12%), Recurrent laryngeal nerve palsy (4.5%)
• 5 year OS was 29%

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Transthoracic Esophagectomy

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• Pulmonary complications are more or less
same
• 5 year overall survival was similar – 24%
for transhiatal esophagectomies and 26%
for transthoracic esophagectomies

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• 30 day mortality high in trans thoracic group (
10.6% vs 7.2%) as was the pulmonary
complications and length of stay ( 4days more)
• Anastomotic stricture and vocal cord palsy was
significantly higher in transhiatal group
• 5 year OS was not statistically different 26.6% in
transthoracic and 25.8% in trans hiatal group

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• New update from the author showed OS 34% in
transhiatal and 36% in transthoracic resection –
though lymphnode retrieval is more in trans
thoracic esophagectomy

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Minimally invasive esophagectomy

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• MIE can be performed safely with an overall
operative mortality of 1.68%
• a median ICU stay of 2 days, and a median
hospital stay of 8 days.
• The morbidity of the procedure was acceptable
and similar to or better than most published
series of open esophagectomy.

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• In preliminary comparison of outcomes between the MIE-
neck and MIE-chest groups, median length of ICU and
hospital stay, overall morbidity, and operative mortality
seemed to be similar between the 2 approaches.
• The 30-day mortality was 0.9% in the MIE Ivor Lewis
group and 2.5% in the MIE-Neck group.
• The incidence of recurrent laryngeal nerve (RLN) injury
was significantly lower in the Ivor Lewis MIE-chest
group (1%) than in the MIE-Neck group (P < 0.001).

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TIME trial

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• 115 patients were randomly assigned to minimally invasive
esophagectomy and open esophagectomy with the primary
endpoint of post operative infections within 2 weeks of surgery
• Minimally invasive group were associated with statistically
significant reduction pulmonary infections 9% vs 29% and and
also in hospital pulmonary infections were less in MIE ( 12% vs
34%)
• Hospital stay ( 11 vs 14 days)
• there was no difference detected in 30 days or in hospital
mortality and post operative complications rate were similar

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• in-hospital mortality, one patient in the
open esophagectomy group died from
anastomotic leakage and two in the
minimally invasive group from aspiration
and mediastinitis after anastomotic
leakage.

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• A reduction in in hospital mortality (3% vs 4.6%)
• Pulmonary complications 17.8% vs 20.4
• Other complications are more or less same
• Conclusion: MIE is superior to open
esophagectomy

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Real world data

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JCOG 1409
• JAPAN is conducting a RCT with n=300
patients
• End point is Overall survival
• This is largest trial with survival as
outcome in the debate between MIE vs
open esophagectomy

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• Minimally invasive esophagectomy is the
ideal approach to operate esophageal
cancer
• Reduced morbidity with equivalent
oncological outcomes
• No difference in routine community
practice

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Extended esophagectomy

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• 174 patients underwent 3 field lymphadenectomy
• A total of 23% of patients with adenocarcinoma and 25%
of those with SCC had positive cervical nodes
• 5 year survival for patients with positive cervical nodes
was 27% for SCC And 12% in adenocarcinoma patients

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• Authors suggest that 3 field
lymphadenectomy may have a role in
patients with SCC and this remains
investigational for patients with
adenocarcinoma

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TATA MEMORIAL

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Palliation

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TROG 03.01NCIC CTG ES2

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DUTCH SIREC study group

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• If patient requires rapid palliation – laser
or stent placement are recommended
• EBRT with or without Chemotherapy
takes at least 2 weeks to produce
palliation, but once palliation is achieved it
is more durable

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Thank You…..!