Diseases and Disorders
The rate of esophageal cancer continues to increase in Western countries due to the epidemic of gastroesophageal reflux disease. Approximately 17,000 new cases will be diagnosed in the United States in 2011, a figure that has been increasing year after year. Many people have a nihilistic view of esophageal cancer, but USC thoracic surgeons have established an international reputation in the successful treatment of this disease with outcomes that are far superior to national and international benchmarks. Moreover, surgery for esophageal cancer is complex and is not done frequently at many hospitals, leading to a lack of familiarity in dealing with this disease. At USC there is a high volume of esophageal cancer patients referred for treatment, and there is a high level of expertise on the part of thoracic surgeons, anesthesiologists, and nurses in the care of these patients, which translates into decreased complications and safer outcomes.
- Extensive experience in the management of esophageal cancer with one of the largest volumes in the United States
- Tailoring the operation to the individual patient’s circumstances
- Unique surgical approaches such as minimally invasive surgery or vagus nerve preservation when appropriate
- Endoscopic therapy for early cancers to maximize the chance for esophageal preservation
- High-volume referral center with knowledgeable thoracic surgeons, nurses, and staff that directly translates into superior outcomes
- Access to multidisciplinary care through Norris Cancer Center with expert oncologists with experience in the adjuvant treatment of esophageal cancer
Mechanism of Disease
There are two types of esophageal cancer – squamous cell carcinoma and adenocarcinoma. In the past, squamous cell carcinoma of the upper or mid esophagus was the most common type of esophageal cancer as a result of excessive smoking and alcohol consumption. Over the past few decades, a shift has occurred and now adenocarcinoma of the lower esophagus or junction between the esophagus and stomach has become the most common. This is a direct result of the increased prevalence of gastroesophageal reflux disease. As chronic reflux injures the lining of the esophagus, the cells change into a premalignant condition known as Barrett’s esophagus. Further injury and genetic changes can allow Barrett’s to progress into dysplasia, and finally into invasive adenocarcinoma.
The diagnosis of esophageal cancer requires an endoscopic tissue biopsy, and allows further subtyping into squamous cell carcinoma or adenocarcinoma. The thoracic surgeon will usually repeat this endoscopy to examine the extent of tumor, the anatomy, and to determine if the stomach can be used for reconstructing the esophagus following esophagectomy. Once the diagnosis of cancer is made, the next step is to stage the disease, or determine how extensive the cancer involves. This typically requires an endoscopic ultrasound to look at the depth of the tumor’s invasion into the esophageal wall and to determine if any lymph node spread has occurred. A PET/CT scan is also obtained to survey the body and determine if there is evidence of spread of tumor cells into remote organs, such as the liver or lungs. Once the staging process has been completed, the treatment options can be tailored to the patient’s circumstances.
The mainstay of therapy of esophageal cancer is complete surgical resection. At USC, the operation that has been designed for most cases is the en bloc esophagectomy. The philosophy behind this operation is not only to remove the esophagus and its tumor, but also to remove as much of the lymph node tissue surrounding the esophagus as possible. Only in this manner can one remove all potential regional sites of tumor spread to maximize the chances of cure. To do so, the surgeon must operate in the chest and abdomen, and reconstruct the esophagus using part of the stomach that is constructed into a narrow tube. This gastric tube is then brought up into the neck and reconnected to healthy esophagus to restore the alimentary tract. The patient therefore requires an incision in the neck, chest, and abdomen for the complete operation. [FIGURE]
In some cases, other types of esophagectomy are employed, again tailoring the therapy that is appropriate to the individual patient. A transhiatal esophagectomy involves removing the esophagus completely from the abdomen and reconstructing it using the gastric tube, which is connected to healthy esophagus in the neck. A chest incision is not required. A vagal sparing esophagectomy involves stripping out the lining of the esophagus and leaving behind the muscular tube. This option has been used for patients with benign disease or those with very superficial cancers. Finally, minimally invasive technology has been applied for all of these types of esophagectomy, and may be done if appropriate for the patient’s circumstances.
For very early cancers that are limited to the superficial layer of the esophagus, endoscopic technology has emerged to treat the cancer and preserve the esophagus. This includes the use of endoscopic mucosal resection (EMR) and endoscopic mucosal ablation (BarrX®). These procedures allow the limited removal of a small nodule as well as burning away of Barrett’s esophagus that harbors high grade dysplasia or early intramucosal cancer. Once successfully treated, these patients often require an antireflux operation to protect the esophagus from ongoing injury from reflux.
Chemotherapy and radiation therapy are other forms of therapy that are commonly used in the treatment of esophageal cancer. The use of chemotherapy and/or radiation is selective, and may be used before or after surgery. The decision to utilize these therapies is personalized and based on the stage of the cancer and the results of the endoscopy, endoscopic ultrasound, PET/CT scan, or pathology of the surgical specimen. The thoracic surgeons at USC play a very active role in determining the use of these therapies and communicate directly with the oncologists in order to coordinate the best treatment plan for the patient.
Esophagectomy is a highly complex operation that should only be done at centers with high volume and experience. USC thoracic surgeons have been pioneers in esophageal surgery, and the team of caregivers is familiar with the perioperative issues that are unique to esophageal cancer patients. This dedication and focus has been directly responsible for the superior outcomes observed in our patients. The extent of lymph node dissection that is done by USC thoracic surgeons is in the 99th percentile of surgeons in this country, and gives excellent local and regional control of the disease process. The survival rates of USC patients have been noteworthy, and have been the subject of several publications and presentations at international meetings.
One major focus in esophageal cancer research is to predict which patients need chemotherapy following esophagectomy. This is especially important in those patients with early stage disease, as some of whom will have a recurrence in the future despite limited disease at the time of surgery. These high risk patients appear to have especially aggressive tumors, and USC researchers are attempting to identify these individuals using genetic expression markers. In the near future, it is hoped that genetic profiling of esophageal tumors will allow identification of high risk individuals who should receive earlier chemotherapy or more intensive surveillance.