Diagnostic laparoscopy may be performed for adenocarcinoma of the distal esophagus and esophagogastric (gastrointestinal) junction to exclude metastases to the liver and/or peritoneum (peritoneum) at advanced stages (especially in the case of a cT3- , cT4-category). The most important therapeutic procedure in squamous cell carcinoma and adenocarcinoma is surgery with the aim of complete removal of the tumor (oral, aboral and circumferential) and regional lymph nodes. Note: Patients with locally advanced esophageal cancer who responded to radiochemotherapy (RCTX) did not benefit from additional surgery compared with continuous RCT in one study (median survival: 19.3 months versus 17.7 months). Both esophagectomy (removal of the esophagus) and esophageal reconstruction can be performed minimally invasively or in combination with open procedures (hybrid technique). The value of minimally invasive procedures cannot yet be conclusively evaluated. In case of preoperative evidence of distant metastasis (metastasis of tumor cells from the site of origin via the blood/lymphatic system to a distant site in the body and growth of new tumor tissue there), surgery should not be performed. Depending on the stage, the following techniques may be performed:
- Endoscopic surgical technique (minimally invasive esophageal resection, MIE) for early stage I adenocarcinoma; patients with a low-grade lesion < 2 cm in extent seem suitable for this – in this case, regional lymph node metastases (daughter tumors in the lymph nodes) were found in only 0, 5% of cases after surgeryNote: Piece-meal resections (ablate piecemeal) have higher recurrence rates (recurrence of disease) than en bloc resections (in whole).
- Radical surgery (subtotal esophagectomy, complete lymphadenectomy (lymph node removal), gastric pull-up) for cT1-T4 or N+, M0.
- The extent of lymphadenectomy depends on the location of the primary tumor, with three fields (abdominal, thoracic, and cervical). Two-field lymphadenectomy represents the standard.
- A combination of radiation and chemotherapy prior to surgery (neoadjuvant radiation chemotherapy) can shrink the tumor to the extent that the tumor can subsequently be removed in toto (in its entirety).
Indications for esophageal resection.
- Lymphatic (L1)- or blood vessel (V1)-infiltration.
- Submucosal infiltration sm2/sm3 or depth invasion ≥ 500 µm.
- Ulceration (ulceration)
- Degree of differentiation G3/G4
- Tumor remnant at basal resection margin (R1 basal).
- Tumor remnant at the lateral resection margin (R1 lateral)
Measures depending on the localization of the tumor.
| Localization | Measures |
| Distal esophagus (including AEG type I) and middle thoracic esophagus. | Transthoracic subtotal esophagectomy (not complete removal of the esophagus by opening the thoracic cavity) |
| Esophagogastric (esophago-gastric) junction (AEG type II) with extensive infiltration of the lower esophagus | Transthoracic subtotal esophagectomyAlternative: transhiatal abdomino-cervical subtotal esophagectomy. |
| Subcardiac tumors (in the proximal portions of the stomach) affecting mainly the gastric mucosa just below the esophagus (AEG type III) | Total gastrectomy with distal esophageal resection (complete removal of the stomach with removal of the lower portion of the esophagus) |
| In the upper thoracic esophagus (esophagus in the upper thoracic region; usually squamous cell carcinoma) | Resection extent should be extended orally to maintain proximal safety margin |
| Cervical esophagus Esophagus in the cervical spine). | Risk-benefit trade-off between surgical approach and radiochemotherapy. |
Further notes
- Even locally advanced esophageal cancer can often be completely removed after pretreatment with neoadjuvant radiochemotherapy (radiotherapy (radiatio) and chemotherapy preceding surgery). Long-term outcomes of 178 patients who received neoadjuvant radiochemotherapy (RCT) showed that 69 (39%) were still alive seven years after surgery….After surgery without pretreatment, this was only 47 of 188 patients (25%). Neoadjuvant radiochemotherapy doubled the median survival time of patients from 24.0 to 48.6 months. In squamous cell carcinoma, it even increased from 21.1 to 81.6 months, and in adenocarcinoma from 27.1 to 43.2 months.