Multimodal management of esophageal carcinoma
With around 6,500 new cases each year, esophageal cancer is a somewhat rare malignancy in Germany, although its incidence is increasing. In about 50 - 60% of cases the tumor is squamous cell carcinoma. In recent years, adenocarcinoma, which is predominantly located in the inferior third of the esophagus, has been diagnosed more frequently.
At the time of diagnosis, only 25% of patients are in an early tumor stages (T1, T2), which is why the 5-year survival rate in Germany is only between 22% and 24% [1]. Evidence-based multimodal management can improve survival from stage cT3 and up and is therefore indicated [2]:
- T1a: Mucosectomy or endoscopic mucosal resection
- T1b to T2: Primarily surgical resection as treatment of choice; in T2 with positive lymph node involvement, preoperative multimodal therapy is optional
- T3 to T4: Preoperative multimodal therapy + surgical resection regardless of any lymph node involvement
In resectable squamous cell carcinoma stage T3 and up, preoperative radiochemotherapy represents the standard, while perioperative chemotherapy and radiochemotherapy are considered equivalent options for adenocarcinoma stage T3 and up. Squamous cell carcinoma may also be cured with definitive radiochemotherapy [2]. Radiochemotherapy focuses on the maximum local effect, while perioperative chemotherapy centers on the optimal systemic effect [3, 4, 5, 6, 7].
Esophageal resection
Surgical treatment of esophageal carcinoma aims at total removal of the tumor, orally, aborally and circumferentially [2]. Due to early lymphogenic metastasis, local endoscopic ablation is only useful in early forms of both squamous cell carcinoma and adenocarcinoma (T1a), while in stages > T1a resection including lymphadenectomy is indicated.
The current standard is abdominal and thoracic 2-field lymph node dissection (2-field LND) with resection of the para-esophageal lymph nodes (LN) in the resection area of the thoracic esophagus (including the infracarinal and parabronchial LNs; thoracic compartment) as well as the abdominal paracardial LNs and the LNs along the celiac trunk and its branches (abdominal compartment). Cervical LND may also be necessary in the case of cancer high up in the chest [2]. Sentinel LND after multimodal therapy is uncertain and therefore not recommended [8]. At present there is no definitive statement on the minimum number of nodes in LND.
In tumors of the middle and distal esophagus, abdominothoracic resection with gastric tube transposition is regarded as standard procedure. If the stomach is not available as a conduit, one alternative would be the colon [2]. A left thoracic approach is possible in the standard procedure, but a more superior right thoracic approach is usually chosen because it provides significantly better exposure of the thoracic LNs, as is also demonstrated in the video (Ivor-Lewis operation [9]). As the level of the esophageal anastomosis increases, anastomotic failure, stricture and dysphagia increase significantly and the quality of life decreases [10]. For this reason, intrathoracic anastomosis is preferred.
In case of tumors of the distal esophagus (Sievert II carcinomas), there are currently no recommendations regarding access via the Ivor-Lewis procedure or extended transhiatal gastrectomy [2]. However, detailed analyses of the so-called Sievert II carcinomas demonstrated a difference depending on the spread of the superior tumor margin into the esophagus. Kurokawa et al [11] found a higher percentage of patients with mediastinal lymph node recurrence after transhiatal resection, which is why in adenocarcinoma at the gastroesophageal junction Ivor-Lewis esophagectomy with proximal gastric resection is increasingly performed instead of extended transhiatal gastrectomy.
The German S3 guideline on "Diagnostics and therapy of squamous cell carcinoma and adenocarcinoma of the esophagus" recommends that both esophagectomy and esophageal reconstruction be performed as minimally invasive procedures or combined with an open approach (hybrid technique) [2]. Since the oncological results so far seem comparable to the open approach, minimally invasive resections may today be regarded as primarily desirable for the patient if it is technically feasible and has the surgeons have the appropriate expertise. Prerequisite is an adequate oncological resection with safe intrathoracic anastomosis [12, 13, 14, 15].