Key Points

• Outcomes after primary resections for esophageal cancer are better than commonly quoted, with recent series reporting 5-year survival rates in excess of 50%.
• En-bloc resection of the esophagus has been reported to result in improved survival and a lower rate of locoregional recurrence compared to standard resection techniques.

Surgical resection has played a central role in the treatment of esophageal cancer for most of the past 100 years. In fact, for most of the last century it was the only available therapy other than palliative treatments such as stenting. Modern linear accelerators that allowed effective radiation therapy to internal organs were not widely available until the 1960s, which is also around the same time that 5 FU and cisplatin chemotherapy were first used in the treatment of solid organ tumors. Since then, alone or in combination, these alternatives to resection have been applied with mixed results. Over the past couple of decades, most of the focus of these combined modality approaches has been on the use of chemotherapy alone or in combination with radiation therapy in the neoadjuvant setting. More than two dozen randomized controlled trials have been published and these have been subjected to several meta-analyses. Sjoquist and colleagues[1] reviewed 24 randomized trials: twelve comparing neoadjuvant chemoradiotherapy to surgery alone, nine comparing neoadjuvant chemotherapy to surgery alone, and two comparing neoadjuvant chemotherapy to neoadjuvant chemoradiotherapy. All cause mortality was lower in patients treated with neoadjuvant chemoradiotherapy compared to surgery alone [HR 0.78 (95% CI 0.70-0.88, p< 0.0001)]. This survival benefit was evident for patients with both adenocarcinoma and squamous cell carcinoma. There was also a significant survival benefit for neoadjuvant chemotherapy compared to surgery alone [HR 0.87 (95% CI 0.79-0.96, p=0.005)] but the benefit varied depending on cell type. The HR for neoadjuvant chemotherapy was significantly lower in patients with adenocarcinoma [HR 0.83 (95% CI 0.71-0.95, p=0.01)] but it was not significantly different in patients with squamous cell carcinoma [HR 0.92 (95% CI 0.81-1.04, p=0.18)]. Kranzfelder and colleagues[2] peformed a metanalysis limited to patients with squamous cell carcinoma with similar findings. Neoadjuvant chemoradiotherapy was associated with improved survival compared to surgery alone [HR 0.81, p=0.008], with no significant benefit to the use of neoadjuvant chemotherapy over surgery alone [HR 0.93, p=0.368]. Based on these results, neoadjuvant therapy has become the standard of care for patients with locoregionally advanced esophageal cancer.

In several of the randomized trials included in these meta-analyses it has been reported that neoadjuvant therapy can result in a complete pathologic response in 5 to 35% of patients with higher rates being reported after preoperative chemoradiation. This has led some to question whether surgical resection is required at all, citing as justification high surgical mortality rates of 10% to 15% and low 5-year survival rates of 20% to 25% after surgery. Recent observations suggest, however, that the results of surgical resection are much better than commonly quoted. In the present era of improvements in perioperative care, with increasing numbers of patients with tumors diagnosed at an earlier stage, modern series from specialty centers report overall survival rates approaching 50% with operative mortality rates of less than 5% (Stein and Siewert, 2004; Portale et al, 2006).[3],[4] Data such as these argue strongly that surgical resection should remain a critical component of the treatment of cancer of the esophagus in the absence of systemic metastases.

When surgical resection is performed, controversy persists with regard to the extent of surgery necessary to achieve cure,[5],[6],[7],[8],[9] with much of the debate centered on the benefits of a systematic lymph node dissection. In this chapter we review our current approach to the management of esophageal cancer, with an emphasis on data to support the application of an en-bloc resection. The important technical aspects of this challenging operation are also described in detail.