Multimodal Therapy of Esophageal Carcinoma
With around 6,500 new cases annually, esophageal carcinoma is a rather rare tumor entity in Germany, but with increasing frequency. In about 50 – 60 % of cases, these are squamous cell carcinomas. Adenocarcinomas, which are predominantly located in the lower third of the esophagus, have been diagnosed more frequently in recent years.
Only 25 % of patients are in an early tumor stage (T1, T2) at the time of diagnosis, which is why the 5-year survival rate in Germany is only between 22 and 24 % [1]. From a stage of cT3, evidence-based multimodal therapy can improve survival and is therefore indicated [2]:
- T1a: Mucosal resection or endoscopic mucosal resection
- T1b to T2: primary surgical resection as the therapy of choice, for T2 with positive lymph node involvement, preoperative multimodal therapy optional
- T3 to T4: regardless of lymph node involvement preoperative multimodal therapy + surgical resection
Preoperative radiochemotherapy represents the standard for resectable squamous cell carcinoma from T3, for adenocarcinoma from T3, perioperative chemotherapy as well as radiochemotherapy are considered equivalent options. For squamous cell carcinoma, definitive radiochemotherapy can also achieve a cure [2]. In radiochemotherapy, the focus is on maximum local effect, in perioperative chemotherapy on optimal systemic effect [3, 4, 5, 6, 7].
Esophageal Resection
The goal of surgical treatment of esophageal carcinoma is complete tumor removal, orally, aborally, and circumferentially [2]. Due to early lymphogenic metastasis, local endoscopic removal is only sensible for both squamous and adenocarcinoma in early forms (T1a), for stages > T1a resection including lymphadenectomy is indicated.
The current standard is the 2-field lymphadenectomy (2-field LAD) abdominal and thoracic with removal of the paraesophageal lymph nodes (LN) in the resection area of the thoracic esophagus (incl. the infracarinal and parabronchial LN; thoracic compartment) as well as the abdominal paracardial LN and the LN along the celiac trunk and its branches (abdominal compartment). For very high-seated carcinomas, cervical LN removal may also be necessary [2]. Sentinel LN removal after multimodal therapy is unreliable and is therefore not recommended [8]. There is currently no definitive statement on the minimum number of lymph nodes to be removed.
For tumors of the middle and distal esophagus, an abdominothoracic resection with gastric tube pull-up is considered the standard procedure. If the stomach is not available as a conduit, colon can be used alternatively [2]. For the standard procedure, a left thoracic approach is possible, but due to the significantly better exposure of the thoracic LN, a higher right thoracic approach is usually chosen, as is also the case in the film example (Ivor-Lewis operation [9]). With increasing height of the esophageal anastomosis, there is a significant increase in leakages, anastomotic strictures and dysphagia and a decrease in quality of life [10], which is why intrathoracic anastomoses are preferred.
For low-seated tumors of the esophagus (Siewert II carcinomas), there are currently no recommendations regarding the resection approach between an Ivor-Lewis operation or a transhiatal extended gastrectomy [2]. Detailed analyses of the so-called Siewert II carcinomas, however, showed a difference depending on the proximal extension of the tumor upper margin into the esophagus. Kurokawa et al [11] found a significantly higher proportion of patients with mediastinal lymph node recurrence after transhiatal resection, which is why for adenocarcinomas at the esophagogastric junction, an Ivor-Lewis esophagectomy with proximal gastric resection is increasingly performed instead of transhiatal extended gastrectomy.
The S3 guideline “Diagnosis and Therapy of Squamous Cell Carcinomas and Adenocarcinomas of the Esophagus” recommends that both esophagectomy and esophageal reconstruction can be performed minimally invasively or in combination with open procedures (hybrid technique) [2]. The oncological results seem comparable to the open approach so far, so that with technical feasibility and appropriate expertise, a minimally invasive resection can today be considered primarily desirable for the patient. Prerequisite is an oncologically adequate resection with secure intrathoracic anastomosis [12, 13, 14, 15].