At the time of presentation almost half of patients with esophageal cancer are not candidates for any curative therapy because of extent of disease or metastases. With the increasing incidence of this disease and the relatively high associated mortality, the question remains how best to treat the 50% of all presenting patients who are operative candidates.

Three major options exist for patients with esophageal cancer who wish to have treatment for curative intent; 1) chemotherapy, 2) radiation therapy, and 3) surgery. As well, some combination of these has been tried with limited success. A literature review and an attempt at evidence based support for the current multimodality therapies used for esophageal carcinoma will be presented in this Virtual Hospital area.

Radiotherapy

Most effective with squamous cell carcinoma, radiotherapy has been used with some success when compared to surgery alone, but only by reducing perioperative morbidity and mortality. Compared to the current results of surgery, radiotherapy alone does not provide long-term relief from dysphagia or any survival advantage, and in fact may be associated with higher complications such as fistulas and strictures. Therefore, at the present time there is no role for radiation alone as the sole treatment for esophageal cancer.

Chemotherapy

Chemotherapy alone has been used only really for cure in the initial stages of esophageal cancer. However, more recent studies have shown that surgery has a significantly better overall result for early stage lesions both in terms of survival as well as quality of life. For more advanced diseases, chemotherapy alone results in a relatively good initial response in about 50% of patients however this is very short lived with symptoms recurring in less than 3 months and is associated with a relatively short survival, rarely longer than one year. Since most of these patients present with dysphagia, they are almost always given both radiotherapy and chemotherapy. Multiple drug regiments have been evaluated with differing levels of success, but the most potent combination seems to be a platin based regimen with 5-FU.  More recently the addition of a taxane has improved results. However, some recent studies have argued that the toxicity of these additional agents may negate the benefits.

While the debate rages about the methods of operative interventions, the goals of surgery are simply two-fold:  1) curative intent and 2) palliation of symptoms. With a significant reduction in morbidity and mortality over the last 10 years surgery has gained an advantage as a palliative therapy.  Except for early stage caners, there is no difference in the cure rate for surgery compared to combined chemotherapy/radiotherapy.  Most recent studies have shown that the survival of patients with stage III esophageal cancers is the same whether patients are treated with chemoradiation or surgery.  Most reports demonstrate that quality of life is better in the surgical group, provided a level of surgical expertise and post-operative care necessary to perform this complex surgery is available.

Importantly, the type of surgical technique used has not been shown to increase long term survival in any study when appropriate comparisons are made. However, the lower complication rate associated with transhiatal esophagectomy has resulted in significant early survival advantages. The ability to avoid a thoracic incision (figure 5) by performing this operation  via the transhiatal approach (figure 6) has resulted in significant improvements in the postoperative course of these patients, with respect to intensive care unit requirements, length of stay, postoperative recovery and morbidity and mortality. 

The following table shows a number of the potential conduits that can be used for different surgical treatments of esophageal cancer.

Figure 7

Figure 8 shows how the stomach is formed into a gastric tube. 

Figure 8

The following three figures illustrate how the anastomosis between the remaining esophagus and the new conduit is performed.

Figure 9

Figure 10

Figure 11

Figure 12 shows the final position of a conduit made from the stomach following a transhiatal esophagectomy.

Figure 12

The current interest in minimally invasive techniques is presently undergoing a trial in comparison to the transhiatal approach, but at the present time even in the best of hands, a minimally invasive approach has not proven to have any advantage in survival and is associated with an increased morbidity and complication rate.  While this may be related to the learning curve, it remains to be seen if there is any long term benefit justifying the higher associated complication rate.

Combined Therapy

Combination therapy has taken many different forms, and multiple techniques, durations and timing of interventions having been developed. The reason for this is that no one method has been proven to increase long term survival to any great extent. The first major consideration is the timing of multimodality intervention:  preoperatively, postoperatively or combination of both.

Preoperative therapy

Trials looking at preoperative radiation therapy alone and preoperative chemotherapy alone have failed to show any significant survival benefit to surgery alone. However, many more trials of combined chemoradiation prior to surgery have more conflicting results.  Overall the survival advantage, if it exists, is small and benefit is seen only in a small select group of patients. One of the major benefits in multiple trials has been the purported benefit of improved resectability. While no real data is available on survival advantages currently for many of these novel trials, we continue to routinely recommend preoperative multimodality treatment for our patients under the age of 70. In our experience, the complication rate for patients over the age of 70 undergoing preoperative chemoradiation followed by surgery was significantly higher than for those undergoing surgery alone.

Title Page