Diagnosis & Surgical Management of Esophageal Malignancies

1. Diagnosis & Surgical Management of Esophageal Malignancies Peter J. DiPasco, MD Assistant Professor of Surgery Department of Surgery – Section of Surgical Oncology The University of Kansas Medical Center Friday, april 4th, 2014 ACOS General Surgery In-Depth Review

2. Disclosure • I have no disclosures

3. Epidemiology Esophageal Adenocarcinoma Melanoma Prostate Others: Breast Lung, Colorectal

4. Demographics • In the United states 80+% of esophageal cancers are adenocarcinomas • Over past 30 years: • 400% increase in white males • 300% increase in white females • 100% increase in African-American males • Male:Female ratio 7:1 • Peak incidence 55 – 65 years old

5. Risk Factors

6. Molecular Biology

7. Esophageal Cancer • Work-up/Staging • Endoscopic Ultrasound • T – Stage • N – Stage • Formal CT scan and PET scan • Metastatic disease • Staging Updates • Changes in new AJCC 7th addition • Squamous Cell versus Adenocarcinoma • Goal to remove 15 lymph nodes

8. Esophageal Cancer • Treatment Overview • Proximal • Definitive Chemoradiation therapy • Metastatic • Definitive Chemoradiaiton therapy • No role for palliative resection • HGD, T1, maybe T2 • Primary Treatment is Surgical • All others • Multimodality approach

10. Diagnostic Endoscopy • Shortcomings: • Currently low positive predictive values for Barrett’s esophagus diagnosis • Possibly improved with magnification chromoendoscopy • Only 5% of patients with Barrett’s esophagus progress to esophageal adenocarcinoma • No data demonstrates that endoscopic surveillance decreases the incidence of advanced cancer and improves survival

11. Alternative “Limited Approach” Treatments of Barrett’s High-Grade Dysplasia(and “Early” [mucosal] Adenocarcinoma)

12. Rationale: • Some “expert centers” claim highly accurate endoscopic detection • Morbidity and mortality of esophagectomy continues to be high • True high-grade dysplasia and early mucosal adenocarcinomas rarely metastasize to lymph nodes

13. Limited Approach • Endoscopic Ablation • Two Categories • Thermal Forms • Photodynamic therapy • Endoscopic Mucosal Resection (EMR) • Combination Ablation / EMR • Limited Resection

14. Endoscopic Ablation • Thermal Forms • Multipolar coagulation • Heat probe therapy • Argon plasma coagulation • Laser therapy (many types) • Radiofrequency ablation • Photodynamic Therapy • Systemic photosensitizer • Preferentially taken up by dysplastic tissue/tumor • Expose tissue to light of specific wavelength • Debride devitalized tissue

15. Endoscopic Ablation • Deficiencies • No tissue removed to assure adequate targeting • Islands of Barrett’s esophagus +/- cancer can still exist under ablated tissue • Surveillance afterward difficult • High stricture rates (30%)

16. Endoscopic Mucosal Resection • Technique • Create pseudo polyp with epinephrine • Snare • Shortcomings • Technically difficult • Difficult to perform in long segment Barrett’s • High recurrence rate (30%) • May have diagnostic value

17. Endoscopic Mucosal Resection Inject and Cut Inject, Lift, and Cut Inject, Suction, and Cut Ligate, then Snare

18. Limited Resection Stein et al. J SurgOnc; 2005, 92:210-217

19. Methods of Esophagectomy

20. TranshiatalEsophagectomy

21. TranshiatalEsophagectomy

23. TranshiatalEsophagectomy

24. TranshiatalEsophagectomy

25. Ivor-Lewis Esophagectomy

26. Ivor-Lewis Esophagectomy

27. Radical Lymphadenectomy vs. Limited • No data supports a superiority of either approach • Overall survival unchanged • Latest NCCN guidelines rather identify a minimum number of nodes to obtain

28. Morbidity & Mortality: Esophagectomy 

29. Hospital-Volume Outcome: Esophagectomy Metzger et al. DisEsoph; 2004, 17:310-314 < 5 5 - 10 11 - 20 > 20

30. Chemotherapy and Radiation Therapy for Esophageal Cancer

31. Neoadjuvant Chemotherapy +/- Radiation Therapy • Rationale • Down-staging of tumor • Increase “resectability” rate • Improve the ability of surgeon to perform a complete (R0) oncologic resection • Potentially prevent systemic spread at the earliest time-point of treatment • Tumor “oxygenation” may be better prior to surgery, thus enhancing effectiveness • Better compliance than if given post-operative • Better assessment of biology of tumor • 20% have complete pathologic response • Recent data has shown a survival advantage

32. Adjuvant Chemotherapy Large Randomized Prospective Studies(*versus Surgery Alone) • No large randomized prospective studies performed for adenocarcinoma • Possibly due to high morbidity and mortality of surgery – i.e. poor compliance • Several advantages to neoadjuvant therapy • Recent Meta-analyses show modest survival advantage

33. Definitive ChemoRadiationTherapy Large Randomized Prospective Studies(***versus Surgery Alone) • No study ever performed • Recent studies show similar survival when compared to historical controls • Indications • Unresectable tumor or metastatic disease • Medically unfit patient • Cervical esophageal cancer

34. Chemoradiation TherapySummary • Resectable advanced non-metastatic dz • Neoadjuvant Rx is standard of care • Patients also receive post-op chemotherapy • Regimens • Paclitaxel and carboplatin • Cisplatin and infusional 5-FU • Current trends • Substitute oxaliplatin for Cisplatin • Substitute capecitabine for 5-FU • Metastatic or Unresectable dz • Triple “definitive” therapy • Docetaxel + cisplatin and 5-FU or • Epirubicin + platinum + 5-FU • Can substitute utilizing oxaliplatin and capecitabine • Add anti-HER-2 therapy when appropriate • 30% of patients

35. Palliative Therapy • Epidemiology • >50% patients are inoperable due to: • Unresectable tumor • Metastatic disease • Poor medical condition • Goal • Relieve dysphagia rapidly with no hospital stay • Basic principles • Currently, no indication for “palliative esophagectomy” • Treatment should be individualized • Wide range of options

36. CASE STUDY • 55M with daily sx’s of reflux for 15yrs • 15lb unintentional weight loss x2mos • PCP orders esophagram – distal mucosal irregularity – refers to you • Diagnostic tests? • Imaging? • Staging? • Surgical Plan?