Morbidity & Mortality: Esophagectomy
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Transcript Morbidity & Mortality: Esophagectomy
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?