Diagnosis & Surgical Management
of Esophageal Malignancies
PETER J. DIPASCO, MD
ASSISTANT PROFESSOR OF SURGERY
DEPARTMENT OF SURGERY – SECTION OF SURGICAL ONCOLOGY
THE UNIVERSITY OF KANSAS MEDICAL CENTER
FRIDAY, APRIL 4TH, 2014
ACOS GENERAL SURGERY
IN-DEPTH REVIEW
Disclosure
 I have no disclosures
Epidemiology
Esophageal
Adenocarcinoma
Melanoma
Prostate
Others: Breast
Lung, Colorectal
Demographics
 In the United states 80+% of esophageal cancers are
adenocarcinomas
 Over past 30 years:



400% increase in white males
300% increase in white females
100% increase in African-American males
 Male:Female ratio 7:1
 Peak incidence 55 – 65 years old
Risk Factors
Molecular Biology
Esophageal Cancer
 Work-up/Staging
 Endoscopic Ultrasound
T – Stage
 N – Stage


Formal CT scan and PET scan

Metastatic disease
 Staging Updates
 Changes in new AJCC 7th addition
Squamous Cell versus Adenocarcinoma
 Goal to remove 15 lymph nodes

Esophageal Cancer
 Treatment Overview
 Proximal


Definitive Chemoradiation therapy
Metastatic
Definitive Chemoradiaiton therapy
 No role for palliative resection


HGD, T1, maybe T2


Primary Treatment is Surgical
All others

Multimodality approach
Diagnostic Endoscopy
 Shortcomings:
 Currently low positive predictive values for Barrett’s esophagus
diagnosis



Possibly improved with magnification chromoendoscopy
Only 5% of patients with Barrett’s esophagus progress to
esophageal adenocarcinoma
No data demonstrates that endoscopic surveillance decreases the
incidence of advanced cancer and improves survival
Alternative
“Limited Approach” Treatments
of
Barrett’s High-Grade Dysplasia
(and “Early” [mucosal] Adenocarcinoma)
Rationale:
 Some “expert centers” claim highly accurate
endoscopic detection
 Morbidity and mortality of esophagectomy continues
to be high
 True high-grade dysplasia and early mucosal
adenocarcinomas rarely metastasize to lymph nodes
Limited Approach
 Endoscopic Ablation
 Two Categories
Thermal Forms
 Photodynamic therapy

 Endoscopic Mucosal Resection (EMR)
 Combination Ablation / EMR
 Limited Resection
Endoscopic Ablation
 Thermal Forms
 Multipolar coagulation
 Heat probe therapy
 Argon plasma coagulation
 Laser therapy (many types)
 Radiofrequency ablation
 Photodynamic Therapy
 Systemic photosensitizer



Preferentially taken up by dysplastic tissue/tumor
Expose tissue to light of specific wavelength
Debride devitalized tissue
Endoscopic Ablation
 Deficiencies
 No tissue removed to assure adequate targeting
 Islands of Barrett’s esophagus +/- cancer can still exist under
ablated tissue
 Surveillance afterward difficult
 High stricture rates (30%)
Endoscopic Mucosal Resection
 Technique
 Create pseudo polyp with epinephrine
 Snare
 Shortcomings
 Technically difficult
 Difficult to perform in long segment Barrett’s
 High recurrence rate (30%)
 May have diagnostic value
Endoscopic Mucosal Resection
Inject and Cut
Inject, Lift, and Cut
Inject, Suction, and Cut
Ligate, then Snare
Limited Resection
Stein et al.
J Surg Onc; 2005, 92:210-217
Methods of Esophagectomy
Transhiatal Esophagectomy
Transhiatal Esophagectomy
Transhiatal Esophagectomy
Transhiatal Esophagectomy
Ivor-Lewis Esophagectomy
Ivor-Lewis Esophagectomy
Radical Lymphadenectomy vs. Limited
 No data supports a
superiority of either
approach
 Overall survival
unchanged
 Latest NCCN guidelines
rather identify a
minimum number of
nodes to obtain
Morbidity & Mortality: Esophagectomy

Hospital-Volume Outcome: Esophagectomy
Metzger et al. Dis Esoph; 2004, 17:310-314
<5
5 - 10
11 - 20
> 20
Chemotherapy and Radiation
Therapy for Esophageal Cancer
Neoadjuvant Chemotherapy +/- Radiation
Therapy
 Rationale
 Down-staging of tumor
Increase “resectability” rate
 Improve the ability of surgeon to perform a complete (R0) oncologic
resection

Potentially prevent systemic spread at the earliest time-point
of treatment
 Tumor “oxygenation” may be better prior to surgery, thus
enhancing effectiveness
 Better compliance than if given post-operative
 Better assessment of biology of tumor



20% have complete pathologic response
Recent data has shown a survival advantage
Adjuvant Chemotherapy Large Randomized Prospective
Studies
(*versus Surgery Alone)
 No large randomized prospective studies performed for
adenocarcinoma



Possibly due to high morbidity and mortality of surgery – i.e. poor
compliance
Several advantages to neoadjuvant therapy
Recent Meta-analyses show modest survival advantage
Definitive ChemoRadiation Therapy Large
Randomized Prospective Studies
(***versus Surgery Alone)
 No study ever performed
 Recent studies show similar survival when
compared to historical controls
 Indications



Unresectable tumor or metastatic disease
Medically unfit patient
Cervical esophageal cancer
Chemoradiation Therapy
SUMMARY
 Resectable advanced non-metastatic dz
 Neoadjuvant Rx is standard of care


Patients also receive post-op chemotherapy
Regimens



Paclitaxel and carboplatin
Cisplatin and infusional 5-FU
Current trends
• Substitute oxaliplatin for Cisplatin
• Substitute capecitabine for 5-FU
 Metastatic or Unresectable dz
 Triple “definitive” therapy




Docetaxel + cisplatin and 5-FU or
Epirubicin + platinum + 5-FU
Can substitute utilizing oxaliplatin and capecitabine
Add anti-HER-2 therapy when appropriate

30% of patients
Palliative Therapy
 Epidemiology
 >50% patients are inoperable due to:
Unresectable tumor
 Metastatic disease
 Poor medical condition

 Goal
 Relieve dysphagia rapidly with no hospital stay
 Basic principles
 Currently, no indication for “palliative esophagectomy”
 Treatment should be individualized

Wide range of options
CASE STUDY
 55M with daily sx’s of reflux for 15yrs
 15lb unintentional weight loss x2mos
 PCP orders esophagram – distal
mucosal irregularity – refers to you
 Diagnostic tests?
 Imaging?
 Staging?
 Surgical Plan?