Thoracoscopic Staging and Surgical Therapy for Esophageal Cancer

doi:10.1378/chest.107.6_Supplement.218S

Chest

Volume 107, Issue 6, Supplement, June 1995, Pages 218S-223S

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Esophageal cancer continues to be a major health problem with an associated poor prognosis. New technology is being applied to the staging of this cancer. The new staging system requires assessment of depth of wall penetration and lymph node status prior to resection. To determine penetration and node status with a high degree of accuracy generally requires some combination of chemotherapy, magnetic resonance imaging, endoesophageal ultrasound, and/or surgical staging. Several variables need to be considered in planning the surgical approach to the patient with esophageal cancer: the intent of the surgeon to either cure or palliate, the anatomic location of the tumor, and the method of reconstruction. Surgery is optimal for localized esophageal cancer. Neoadjuvant chemoradiation has increased survival in specific subgroups. Phase 2 trials have shown the safety and efficacy of chemoradiation. Randomized multi-institutional trials are needed to verify the encouraging results of recent phase 2 trials.

Section snippets

Esophageal Staging Systems

Accurate staging of esophageal cancer is important to assess new treatments and advise individual patients of prognosis. The TNM classification, based on independent measures of primary tumor size, regional lymph node involvement, and distant metastases, forms the basis for stratifying patients with esophageal cancer into prognostic stage groups.

International consensus for esophageal cancer staging was reached in 1987 and in 1988, with worldwide approval from all national TNM committees for the

Staging Techniques

To assess depth of wall penetration and lymph node status with a high degree of accuracy prior to resection generally requires some combination of computed tomography (CT) scan, magnetic resonance imaging (MRI), endoesophageal ultrasound (EUS), and/or surgical staging. Surgical-pathologic staging of patients with esophageal cancer, we believe, should form the basis of protocol development, design, and evaluation. It is hoped that refinement of such protocols will ultimately affect the dismal

Surgical Therapy

Several variables need to be considered in planning the surgical approach to the patient with esophageal cancer: the intent of the surgeon to either cure or palliate, the anatomic location of the tumor, the method of reconstruction, and the overall clinical setting, ie, the patient's overall health and ability to comply with complicated regimens.

Neoadjuvant Therapy

Preoperative RT has been used in an attempt to improve overall results in patients with esophageal cancer.30, 31, 32, 33 Most investigators have used 40 Gy given over 4 weeks, with surgery performed 4 weeks later. Clifton et al³³ reported an increase in resectability rate from 58 to 79% with preoperative RT. This observation was confirmed by Akakura et al³⁴ but challenged by Launois et al.³² Preoperative RT does not seem to adversely affect operative mortality or morbidity.30, 31, 32 Most

Conclusions

Esophageal cancer continues to be a major health problem with an associated poor prognosis. New technology is being applied to the preresectional staging of this cancer. Accurate pathologic staging allows the identification of subgroups of patients who may benefit most from new combined-modality treatments.

Surgery is optimal for localized esophageal cancer. Neoadjuvant chemoradiation has increased survival in specific subgroups. Phase 2 trials have demonstrated the safety and efficacy of

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Cited by (22)

Staging in oesophageal cancer
2006, Best Practice and Research: Clinical Gastroenterology
Citation Excerpt :
The overall staging accuracy of EUS in depth of tumour invasion (T stage) is 85–90%, as compared to 50–80% for CT. The accuracy in detecting regional nodal involvement (N1) is around 70–80% for EUS and 60–80% for CT.47–50 Some surgical centres have used thoracoscopy and laparoscopy in oesophageal cancer staging with an increased yield of distant metastases of 15–20%, particularly in gastro-oesophageal tumours and in the advanced stages.51–53 FDG-PET is more specific than CT and EUS in the identification of locoregional lymph-node metastases.
Accurate staging defines groups for stage-specific treatment, minimising inappropriate treatment. Application of dedicated staging methods – including 16–64 multidetector computed tomography (CT), endoscopic ultrasonography with fine-needle aspiration (EUS-FNA) and positron emission tomography (PET) – results in better staging of oesophageal cancer. PET as a metabolic imaging technique that is usually applied after (or recently in combination with) CT (PET/CT) improves the accuracy of non-invasive staging, especially in locally advanced oesophageal cancer patients. Whether EUS-FNA or PET/CT should be performed as a first diagnostic step is still a matter of debate. Fluoro-2-deoxyglucose (FDG) PET is also promising tool in assessing neoadjuvant treatment response. Application of these dedicated staging methods has a learning curve, suggesting a prominent role for centralisation.
Staging and preoperative evaluation of upper gastrointestinal malignancies
2004, Seminars in Oncology
Esophageal and gastric cancers are distinct carcinomas of the upper gastrointestinal tract, although the distinction between them becomes less clear at the gastroesophageal junction (GEJ). Increasingly accurate staging is possible based on newer radiographic and surgical techniques such as positron emission tomography (PET), laparoscopy and thoracoscopy, laparoscopic ultrasound, and endoscopic ultrasound (EUS). For both cancer types, tumor classification is determined by depth of penetration of the primary tumor into the gastric or esophageal wall. For esophageal cancer, primary tumor anatomic position-upper, mid, and lower esophagus-is used to define the local nodal basin. Metastases in nodes outside the local basin are considered to be distant (M) rather than regional (N). In gastric cancer, the region of nodal metastasis has been abandoned in favor of the number of lymph nodes containing metastasis, which predicts outcome more accurately—patients with more than 15 positive lymph nodes have an outcome comparable to those with M disease. Increasing consideration is being given to the subclassification of tumors near the GEJ into types based on anatomical position, although this staging scheme (“ $A$ denocarcinoma of the $E$ sophago $G$ astric junction” or AEG type) has not yet been universally adopted. We review the current pathologic staging systems for esophageal and gastric cancers, the clinical staging approaches for these diseases, and the controversy surrounding classification of tumors of the GEJ.
18-Fluorodeoxyglucose positron emission tomography in nonendocrine neoplastic disorders of the gastrointestinal tract
2003, Gastroenterology
Thoracoscopic and laparoscopic lymph node staging in esophageal cancer: Do Clinicopathological factors affect the outcome?
2002, Annals of Thoracic Surgery
Background. This study was performed to evaluate the pattern of lymphatic metastases found by combined thoracoscopic (TS) and laparoscopic (LS) lymph node staging in esophageal cancer, and ascertain whether clinicopathologic factors may be used to guide the clinical practice of combined TS and LS staging.
Methods. A retrospective study was performed in a series of 76 esophageal cancer patients who had undergone both TS and LS staging before treatment. The correlation of TS and LS lymph node metastases with clinicopathologic factors was analyzed, including the clinical T stage, clinical N stage, tumor location, and histology.
Results. Thirty-one patients (40.8%) were found to have lymphatic metastasis by TS and LS staging. Among them, 22 patients had abdominal lymph node metastases, 7 patients had mediastinal lymph node metastases, and 2 patients had both. Patients with advanced T stage (T3 to T4) or adenocarcinoma had a higher frequency of abdominal lymphatic metastases than patients with early T stage (T1 to T2) (39% vs 16%; p = 0.04) or squamous cell carcinoma (39% vs 20%; p = 0.079), respectively. Patients with clinical abdominal N1 stage had a higher incidence of positive laparoscopic finding than patients with clinical abdominal N0 stage (67% vs 23%; p = 0.001). There was no significant correlation between lymphatic metastases and the location of the primary tumor.
Conclusions. Clinicopathologic factors, including the histologic type, the clinical T stage, and abdominal N stage, may affect the outcome of TS and LS lymph node staging in esophageal cancer patients. This clinicopathologic impact may play a role for the selection of candidates for TS and LS staging, and also allows surgeons to focus their attention on the most likely high-yield biopsy targets.
Making sense of multimodality therapy for esophageal cancer
1999, Surgical Oncology Clinics of North America
The results of single modality treatment for esophageal cancer have been poor because of a high rate of local recurrence and distant metastasis. This is probably caused by the prevalence of advanced esophageal cancer at the time of diagnosis; only 3% of patients have Stage I disease, and most of them (80%) are Stage III or IV when they become symptomatic. The most frequently involved metastasis sites are lymph nodes (73%), lung (52%), and liver (47%). Neoadjuvant preoperative chemotherapy, radiotherapy, and combined chemoradiation have been added to the treatment of this disease to enhance local control, increase resectability rate, and improve disease-free survival. The results of recent trials are discussed.
Esophageal cancer
1999, American Journal of Gastroenterology

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Chest

Thoracoscopic Staging and Surgical Therapy for Esophageal Cancer

Section snippets

Esophageal Staging Systems

Staging Techniques

Surgical Therapy

Neoadjuvant Therapy

Conclusions

Ann Thorac Surg

Gastroenterology

Ann Thorac Surg

Ann Thorac Surg

Am J Surg

Am J Surg

Ann Thorac Surg

Chest

J Thorac Cardiovasc Surg

Cancer statistics

CA Cancer J Clin

Rising incidence of adenocarcinoma of the esophagus and gastric cardia

JAMA

Preoperative staging of esophageal cancer: comparison of endoscopic US and dynamic CT

Radiology

Improved assessment of supraclavicular and abdominal metastases in oesophageal and gastro-oesophageal junction carcinoma with the combination of ultrasound and computed tomography

Br J Radiol

Staging of esophageal carcinoma: comparison of results with endoscopic sonography and CT

AJR

Computed tomography for staging esophageal cancer: reevaluation

AJR

Preoperative staging and risk analysis in esophageal carcinoma

Hepatogastroenterology

Esophageal ultrasound and the preoperative staging of carcinoma of the esophagus

J Thorac Cardiovasc Surg

Preoperative TNM classification of esophageal carcinoma by endosonography

Hepatogastroenterology