Primary Surgery for Adenocarcinoma of the Esophagus
Although esophagectomy remains a corner stone of the curative treatment of esophageal adenocarcinoma the role of “primary” resection has receded in the past decade in favor of multi-modality or endoscopic therapy. For example, in 1997 the Commission on Cancer of the American College of Surgeons initiated a study of the patterns of care for esophageal cancer in the community in 1994. Using data from the American College of Surgeons National Cancer Database (NCDB) the study examined the modalities of treatment offered to more than 5000 patients in over 820 hospitals across the United States in 1994. This study, reported in 2000 by Daly and colleagues, showed that although esophagectomy was the most common treatment modality for esophageal adenocarcinoma, it was only offered to 33% of 2031 patients clinically staged as stages I, II, and III. Amazingly, the data on recurrence within one year of surgery showed that only 33% of patients remained free of recurrence at one year, while 30.7% were never rendered disease free by surgical resection and another 36.4% developed local, regional and/or systemic recurrence within the first post-operative year. Therefore, it comes as no surprise, that even as early as 1994 when the data on multi-modality therapy was sparse, the majority of patients were treated with preoperative chemotherapy or chemoradiation with or without esophagectomy. In our own unpublished analysis of data from the NCDB (2004-20014) that included 38,449 patients with clinical stages T0-T3/N0-N1, esophagectomy alone was employed in 10% of patients while 36% of patients had surgery after induction therapy and another 30% had definitive chemoradiation (unpublished observation). Among all patients who underwent an esophagectomy only 20% had primary esophagectomy without preoperative therapy. In a similar analysis of the SEER data-base, Worni et al examined the trends in treatment of clinical T1-T3/N1M0 esophageal cancer patients between 1998 and 2008. Among the 3295 patients identified, 21% underwent surgery alone, 40% had radiation alone and 39% had bimodality therapy. Interestingly, the authors found that between 1998 and 2008, the use of bimodality therapy increased from 33% to 43% and conversely the use of surgery alone decreased from 38% to 12.7%. Additionally, data from population and administrative data-bases suggest that the use of primary esophagectomy is also decreasing in patients with clinical T0/T1 cancers. A recent study from the NCDB that included 52,122 patients between 2004 and 2013 with clinical stages 0-III, showed that for patients with clinical stage 0, the rate of esophagectomy decreased from 24% to 18% while local therapy (mainly endoscopic) increased from 34% to 59%. For clinical stage I disease, esophagectomy rates increased moderately from 30% to 34% likely due to increased utilization in the community of endoscopic procedures.
In summary, the data stongly suggest that primary esophagectomy is now uncommonly practiced in patients with locally advanced esophageal adenocarcinoma. This trend is likely multifactorial but is undoubtedly infleunced by recent level I evidence favoring trimodality therapy over surgery alone. There is also a similar trend favoring endoscopic resectional/ablative approaches over esophagectomy for patients with clinical T1 cancers. Although endoscopic resections for T1a lesions seems justified by the best available evidence, more widespread application of these techniques to all T1 tumors appears to be increasingly popular despite the absence of solid supporting evidence. Notwitstanding the above discussion it is clear that at least some patients continue to be treated by primary esophagectomy without preoperative therapy. Whether that approach is based on specific appropriate indications or deviation from current guidelines is unclear. In the following discussion we will attempt to outline what we believe to be the appropriate circumstances in which patients with esophageal adenocarcinoma can be reasonably offered primary esophagectomy without preoperative therapy. Additionally, there is considerable controversy within the surgical literature as to what represents the appropriate operation for patients with esophageal cancer, regardless of cell type. The debate focuses primarily on the need for, and the extent of, lymph node dissection during the conduct of esophagectomy for cancer. We will also attempt to outline the various surgical strategies and their impact on survival and disease recurrence, focusing on patients with adenocarcinoma.
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