Which test most accurately assess the T stage of esophageal cancer?
For years, clinical staging, contrast radiography, endoscopy, and CT scanning formed the backbone of esophageal cancer staging. More recently, preoperative decision making is guided by endoscopic ultrasonography (EUS) and positron emission tomography (PET) scanning.
EUS provides the most reliable method of determining depth of cancer invasion. In the absence of enlarged LNs, the degree of wall invasion dictates surgical therapy.
Which of the following patients would not be considered a candidate for esophagectomy?
If the tumor invades into the submucosa, without visible LN involvement, most individuals would suggest esophagectomy with LN dissection, as positive nodes can be found in 20 to 25% of those with cancer limited to the mucosa and submucosa. If EUS demonstrates spread through the wall of the esophagus, especially if LNs are enlarged, then induction chemoradiation therapy (neoadjuvant therapy) should be strongly considered. Lastly, when the EUS demonstrates invasion of the trachea, bronchus, aorta, or spine, then surgical resection is rarely indicated. If there is invasion into the pleura (T4a), then surgical resection can be considered in the absence of a malignant effusion. Thus, it can be seen that the therapy of esophageal cancer is largely driven by the findings of an endoscopic ultrasonography. It is difficult to provide modern treatment of esophageal cancer without access to this modality.
The technique of resecting an esophageal cancer which remains symptomatic after definitive chemoradiotherapy is referred to as:
Salvage esophagectomy is the nomenclature applied to esophagectomy performed after failure of definitive radiation and chemotherapy. The most frequent scenario is one in which distant disease (bone, lung, brain, or wide LN metastases) renders the patient nonoperable at initial presentation. Then, systemic chemotherapy, usually with radiation of the primary tumor, destroys all foci of metastasis, as demonstrated by CT and CT-PET, but the primary remains present and symptomatic. Following a period of observation, to make sure no new disease will become evident, salvage esophagectomy is performed, usually with an open two-field approach. Surprisingly, the cure rate of salvage esophagectomy is not inconsequential. One in four patients undergoing this operation will be disease free 5 years later, despite the presence of residual cancer in the operative specimen. Because of the dense scarring created by radiation treatment, this procedure is the most technically challenging of all esophagectomy techniques.
Patients with dysphagia secondary to esophageal cancer treated with radiation can expect the benefit to last:
Primary treatment with radiation therapy does not produce results comparable with those obtained with surgery. Currently, the use of radiotherapy is restricted to patients who are not candidates for surgery, and is usually combined with chemotherapy. Radiation alone is used for palliation of dysphagia but the benefit is short-lived, lasting only 2 to 3 months. Furthermore, the length and course of treatment are difficult to justify in patients with a limited life expectancy. Radiation is effective in patients who have hemorrhage from the primary tumor.
How long after completion of neoadjuvant chemoradiotherapy should esophagectomy be performed?
The timing of surgery after chemoradiation induction is generally felt to be optimal between 6 and 8 weeks following the completion of induction therapy. Earlier than this time, active inflammation may make the resection hazardous, and the patients have not had time to recover fully from the chemoradiation. After 8 weeks, edema in the periesophageal tissue starts to turn to scar tissue, making dissection more difficult. With chemoradiation, the complete response rates for adenocarcinoma range from 17 to 24%. No tumor is detected in the specimen after esophagectomy. Patients demonstrating a complete response to chemoradiation have a better survival rate than those without complete response, but distant failure remains common.
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