role of surgery in early esophageal carcinoma

1. Role of surgery in early
esophageal cancer
Dr Rajiv Paul
DNB trainee
Dept of Surgical Oncology
RGCI

2. Introduction
 5th most frequent cancer worldwide and 6th leading cause
of mortality.
 Marked change in ratio of SCC to adenocarcinoma over the
last two decades.
 Increasing incidence of early esophageal cancer particularly
in western countries.

3. Superficial Esophageal Carcinoma
Japanese Esophageal Society
Esophagus 2009;6:1-25
T1a + T1b
AJCC/TNM 7th Edition
Early Esophageal Carcinoma
Japanese Esophageal Society
Esophagus 2009;6:1-25
T1a
AJCC/TNM 7th Edition
What is Early Esophageal Cancer?

4. Definition and classification
Early esophageal cancers are
 Tis(high grade dysplasia) and T1 lesions.
 T1a-tumor invades lamina propria and muscularis
mucosa
 T1b-tumor invades submucosa.

5.  For many years, the standard treatment for both HGD and
superficial esophageal cancer has been esophagectomy.
 High cure rates were achieved but at the cost of treatment-
related morbidity and mortality.
 Endoscopic approaches have been increasingly used after
encouraging results in Japan and Europe.
 However, these techniques are only appropriate for patients
who have a very low risk of lymph node metastases or who
are poor candidates for esophageal surgery.

6. Risk factors of LN metastasis

7. Subclassification of Depth of Invasion by Superficial
Carcinoma of the Esophagus in Surgically Resected
Specimens
Endoscopic Resection Specimens
sm1 carcinoma: invades less than 200 microns into the submucosa
Japanese Esophageal Society. Japanese Classification of Esophageal Cancer. !0th Ed.
Esophagus 2009;6:1-25

9.  4 out of 38 patients (10.3%) with M3 lesions without LY
had LNM, whereas five out of 12 patients (41.7%) with
M3 lesions and LY had LNM.
 For M3 tumors without LVI, endoscopic therapy is a
reasonable strategy.

10.  Among 402 patients with superficial squamous cell
esophageal cancer, the cumulative five-year metastasis
rate (both lymphatic and distant) in patients with M3
cancers was 8.7 percent.
 Among patients with mucosal cancer (M1, 2, or 3), the
five-year rate of metastases with and without
lymphovascular invasion was 47 versus 0.7 percent,
respectively.

11.  The rates of LN metastasis and LN recurrence were 16% in sm1, 35% in
sm2, and 62% in sm3 cases.
 The incidence of hematological recurrence was 0% in m1, m2, m3, and
sm1 cases; 9% in sm2 cases; and 13% in sm3 cases.
 The overall risk of metastasis was 9% in m3, 16% in sm1, 38% in sm2,
and 64% in sm3 patients.
 Endoscopic treatments should be avoided in all submucosal tumors.

12. Diagnosis and Staging of
Early (T1a) and
Superficial (T1a+T1b)
Esophageal Carcinoma

13. Endoscopic Diagnosis of
Early Esophageal Carcinoma
Fujinon “FICE”
Olympus “Tri-Modality”

14. Can we predict the risk of lymph node
metastasis?
27%
50%
20%
10%
10%
Incidence of nodal metastasis
Takubo et al. Histopathology 2007;51:733-742

15. High Risk Factors for
Lymph Node Metastasis
 Depth of invasion – T1b
 Morphology – types 0-I and 0-III
 Lymphatic permeation
 Poor histological differentiation
 Tumor size >2cm
 Infiltrative growth pattern
Takubo et al. Histopathology 2007;51:733-742

16. Accuracy of EUS staging
 Endoscopic ultrasound (EUS) is the most accurate
noninvasive method to assess depth of invasion.
 Overall accuracy of EUS for T and N staging is 80 to 90
percent.
 EUS had a sensitivity and specificity for diagnosing T1a
tumors of 85 and 87 percent, respectively.
 For T1b tumors, the sensitivity and specificity were both 86
percent.

17.  If the EUS identifies esophageal cancer that invades the
muscularis mucosa or if there is evidence of lymph
node involvement, then surgical therapy is often
recommended.
 If the EUS identifies only mucosal disease and the
patient is potentially eligible for endoscopic treatment,
an endoscopic resection is then performed to precisely
define the depth of invasion.

18. Endoscopic therapy
 Both therapeutic and staging purpose.
 The available options are ER and various ablation
methods, including RFA, PDT, and cryotherapy.
 Indicated in limited early stage disease .i.e
 Tis and T1a,
 <2cm
 Well or moderately differentiated scc or adeno
 Elderely with multiple comorbidities
 Patient preference

19. Emerging Treatment Paradigm
EMR of all resectable dysplastic lesions
Favourable histology? Multifocality?
Ablation of the remaining Barrett‘s - ?RFA
Endoscopic Surveillance

20. Endoscopic Mucosal Resection as
intermediate staging strategy
 More accurate depth of invasion.
 The pathology result from the endoscopic
resection (particularly the presence or absence of
LVI) can be used to guide the final decision as to
whether endoscopic therapy alone is sufficient
or if surgery should be recommended.

21. Endoscopic resection Vs esophagectomy
 Equivalent long term outcome in HGD and
intramucosal carcinoma.
 Lower morbidity(0% vs 30%).
 Higher recurrence rate 18% at median follow of
43mth (Mayo clinic).
 Majority can be managed by repeat endoscopic
treatment.
 Similar long term complete response rate(98% vs
100%)
 Similar OS and DFS at 5yrs.

22. Esophagectomy in early esophageal
cancer
Rational
 Occult, synchronous, invasive carcinoma has been
detected in a significant proportion of esophagectomy
specimens, averaging 37% in multiple surgical series;
 Invasive cancer may arise within dysplastic BE over
the short to medium term.

23. The potential advantages of esophagectomy include
 Precise pathologic staging information,
 Permanent removal of all Barrett's mucosa at risk
 Treatment is definitive, without the need for
posttreatment surveillance or salvage therapy in
the event of a recurrence.

24. Indications for Esophagectomy
 T1b: ≥20% incidence of nodal metastasis
 Intramucosal M3 tumors with LVI
 Unfavorable histological characteristics
 Poor differentiation
 Lymphovascular invasion
 Multi-focal cancer
 Persistent positive margins after endoscopic treatment
 Long segment lesions not amenable to endoscopic treatment(>2cm)
 Extensive pTis or nodular pT1a not amenable to ER.
 Peri-esophageal lymphadenopathy at EUS

25. Esophagectomy
techniques

26. Cure rate

27. Quality of life
 For patients undergoing esophageal resection for
early neoplasia, when there is a high chance of
cure and a long life expectancy, QOL becomes an
important consideration, especially relative to
the ability to eat and gastrointestinal side
effects.

28. Greene CL, DeMeester SR, Worrell SG, et al
 40 patients who underwent esophagectomy were assessed
at a median follow up of 12 years .
 The majority (88%) reported no dysphagia;
 90% were able to eat 3 meals per day, and 93% were able to
finish 50% of a typical meal.
 Dumping, diarrhea 3 times per day, or regurgitation
occurred in 33% of patients.
 Scores for QOL were at the population mean .
 Other studies have confirmed that QOL, as a whole,
remains normal after esophagectomy.

29. Transhiatal vs. Transthoracic?
 Randomised clinical trial
 Adenocarcinoma: Siewert types 1 or 2
 Final analysis on 205 patients
 No difference in post-operative mortality
 5 year actual survival benefit for transthoracic
operation
Limited to patients with 1-8 positive nodes
Overall survival: 14% benefit
Recurrence-free survival: 41% benefit
Hulscher et al. N Eng J Med 2002;347:1662-9; Omloo et al. Ann Surg 2007;246:992-1000

30. Minimal invasive esophagectomy
 MIE have been designed in an attempt to reduce morbidity and
mortality with equivalent oncologic outcome.
 It includes
 Thoracoscopy
 Laparoscopy
 Combined thoracoscopic and laparoscopic
 Robotic
 These techniques have been applied to all stages of resectable
esophageal carcinoma, but most applicable in early esophageal
carcinoma.

31. Outcomes After Minimally Invasive Esophagectomy
Luketich et al

32. Outcome of MIE in T1 lesion
Luketich et al
 Majority had T1b lesion(90%).
 30 day mortality was 0%.
 R0 resection was achieved in 99%.
 3yr and 5yr OS were 80% and 62%.
 The authors concluded that MIE remain standard of care of
T1 lesions.

33. MIE
Transhiatal vs. Transthoracic
Transhiatal
433 patients
Transthoracic
1499 patients
Vocal cord palsy 10% 6.4%
Leakage 13% 7.6%
Respiratory complic. 22% 22%
Re-operation 3% 6.8%
Mortality 4.6% 2.4%
Lymph node count 10 (5-15) 17 (7-62)
Decker et al. European Journal of Cardio-Thoracic Surgery. 2009;35:13-21

34. Minimally invasive esophagectomy vs open esophagectomy for
esophageal cancer: a meta-analysis. 2016
Lu Lv, Weidong Hu, Yanchen Ren, and Xiaoxuan Wei
 Patients get less respiratory complications (risk ratio =0.74, 95%
CI =0.58–0.94, P=0.01) and better overall survival (hazard ratio
=0.54, 95% CI =0.42–0.70, P<0.00001) in the MIE group than the
OE group.
 No statistical difference was observed between the two groups
in terms of lymph node harvest, R0 resection, and other major
complications.

35. What is the Aim of Esophagectomy?
 T1a/Low-risk for lymph node metastasis – to
eradicate the primary tumor
Conventional laparoscopic transhiatal
operation
Vagus-preserving esophagectomy
Merindino operation
 T1b/High-risk for lymph node metastasis – to
achieve radical lymphadenectomy
Trans-thoracic esophagectomy

36. Laparoscopic Vagus-Sparing
Esophagectomy
 Less extensive operation
 Enhanced perfusion of gastric conduit
 No need for pyloroplasty
 Dumping & diarrhoea in less than 10%
 Less weight loss
 Less infectious complications
 ? cardioprotective
Peyre et al. Ann Surg 2007;246:665-671
DeMeester S. Personal communication, 2010

37. Segmental Resection of the
Gastroesophageal Junction and
Reconstruction with a Pedicled Flap of
Jejunum (Merindino Operation)
• 94 patients
• T1a or T1b adenocarcinoma
• Transhiatal (11) vs. Transthoracic (60) vs.
Merindino (24)
• Similar lymph node retrieval
• Merindino operation:
– Less complications
– No mortality
Stein et al. Ann Surg 2000;232:733-742

38. Summary
• The incidence of early esophageal cancer is increasing globally.
• Two major treatment options are esophagectomy and endoscopic resection
(ER).
• For fit patients with submucosal (T1b) cancer, esophagectomy is
recommended over ER.
• For M1 , M2 tumors and well-differentiated M3 disease without
lymphovascular invasion , ER is a valid alternative if performed at
institutions with expertise in this technique.
• For fit patients with M3 disease and lymphatic invasion, esophagectomy is
recommended.
• Patients needing esophagectomy should be referred to a high-volume center
for better outcome.