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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%

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Presentation on theme: "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%"— Presentation transcript:

1 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.

2 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

3 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

4 Esophageal CA -- find distant mets Distant mets –Bronchoscopy in proximal and middle third esophageal CAs eval. for posterior tracheal invasion –slight compression still resectable –abnormal tracheal mucosa unresectable

5 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

6 Esophageal CA -- eval. lymph nodes Lymph node status –Laparascopic staging Laparscopic ultrasound of liver not useful

7 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 % of the time –Endoscopic ultrasound -- less accurate after neoadjuvant therapy

8 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

9 Esophageal CA -- chemoradiation Treatment of choice for Stage 4 (mets) –Stent esophageal lesion, chemo and radiation SCC responds to radiation better than Adeno CA

10 Esophagectomy -- Types of operations Incision strategies: –Ivor-Lewis Laparotomy, thoracotomy –Transhiatal Conduit strategies: –Gastric pull-up –Colonic interposition –Jejunal interposition

11 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

12 Esophagectomy -- Types of operations Anastomosis strategies: –Technique: Stapled (EEA) –Ease –Strictures Sutured –single layer vs double layer, running vs interrupted

13 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

14 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

15 Esophagectomy -- Intra-operative complications Recurrent laryngeal nerve injury –especially in cervical dissections

16 Esophagectomy -- Operation by stage Barretts 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

17 Esophagectomy -- Operation by stage Barretts 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

18 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

19 Esophagectomy -- Operation by Stage Tumor into or through muscularis propria –75% to 85% LN involvement –45% have > 4 LNs – % 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)

20 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 % –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

21 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

22 Esophagectomy -- Complications Mortality 3 - 5%, Morbidity 15-18% Anastomotic leaks % –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)

23 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

24 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

25 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 sutures –Vague lower thoracic/upper abd. cramping pains –CXR; CT or contrast study if in doubt –Repair with hiatal closure and anchoring sutures

26 Esophagectomy -- Complications Chylothorax –1 - 3% –Ligate intraoperatively when identified –Massive (800 cc/day) chest tube output at 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

27 Esophagectomy -- Complications Anastomotic strictures % –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)

28 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

29 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 months

30 Esophageal CA -- radiation 20 to 40 Gy over 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

31 Esophageal CA -- chemo Pre-operative chemo (Cisplatin, 5-FU) –Only 19% response –No change in survival –No change in local recurrence rates or patterns

32 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

33 Esophageal CA -- chemoradiation Pre-op chemoradiation (cisplatin/5-FU) – Increases surgical M/M by 5-15% With high does radn (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

34 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

35 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)

36 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 Gy with 5 FU/Cisplatin –Comparisons are not against en bloc resections

37 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

38 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 -- cant detect regional nodes well Histologic response -- not avail. without resection Future: biologic serum markers ?


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