Improving Esophageal Cancer Patient Outcomes With Endoscopic and Minimally Invasive Approaches

by Steven Hochwald, MD, FACS
Chief of Gastrointestinal Surgery, Vice Chair of Surgical Oncology

There are predictive factors (both host and environmental) that correlate with increased risk of developing such inflammatory conditions as Barrett's esophagus with dysplasia, which may also predispose patients to esophageal cancer [1]. In these patients, who may already be undergoing endoscopic evaluation, early superficial cancers can be identified, treated, and cured. First developed in Japan by Inoue et al. [2], endoscopic resection (ER) is an important advance in the management of esophageal tumors, and it has a number of potential benefits.

First, it serves as a larger and deeper biopsy specimen, better than any other method currently available, it allows more precise determination of the depth of tumor penetration. This provides more accurate prognostic information in esophageal cancer. In addition, it can be performed with curative intent for low-risk tumors or combined with mucosal ablative therapies for complete removal of esophageal metaplastic or dysplastic epithelium.

Compared with esophagectomy, ER has offered an organ-preserving approach for patients with early esophageal cancer limited to the mucosa (T1a), and the technique has been shown to be safe and effective. There are limited series describing the results of ER for esophageal cancer in North America. Our results have been published recently, demonstrating excellent cancer control with endoscopic therapy [3]. As one of the largest North American studies to date, our study shows that this procedure can be performed safely and with good oncologic outcomes. Experienced esophageal pathologists, endoscopists, and surgeons are crucial in optimizing short- and long-term outcomes for these patients.

Esophagectomy for benign or malignant disease is a complex operation with significant morbidity and mortality. The five-year survival rate has been shown to be 19 to 46 percent with a surveillance program and increased detection of early-stage esophageal cancer. In an effort to reduce the morbidity of esophagectomy, minimally invasive methods were increasingly applied in the 1990s. In 1998, surgeons reported their initial experience on eight patients who underwent minimally invasive esophagectomy (MIE) using either laparoscopic and/or thoracoscopic techniques. They had no perioperative mortalities and one cervical anastomotic leak, thus demonstrating the potential safety and feasibility of minimally invasive esophagectomy. Since then, several institutions, including Roswell Park, have reported their experiences in the adoption and refinement of large numbers of MIE for benign and malignant diseases of the esophagus [4,5].

Approximately 90 percent of Roswell Park Cancer Institute patients with gastric or esophageal cancer who are candidates for surgery will benefit from a minimally invasive surgical approach. Our data demonstrate that operative morbidity is significantly improved after a minimally invasive resection, and there is a more rapid return to preoperative quality of life and improved eligibility to receive adjuvant therapies. Overall, minimally invasive esophagectomy is an integral tool that is safe and effective in the surgical management of esophageal cancer, and it should be the gold standard procedure.

References

  1. Hvid-Jensen F, Pedersen L, Drewes AM, Sørensen HT, Funch- Jensen P. Incidence of adenocarcinoma among patients with Barrett’s esophagus. N Engl J Med 365(15):1375–1383, (2011)
  2. Inoue H, Takeshita K, Hori H, Muraoka Y, Yoneshima H Endo M. Endoscopic mucosal resection with a cap-fitted panendoscope for esophagus, stomach, and colon mucosal lesions. Gastrointest Endosc 39(1):58–62, (1993)
  3. Nurkin SJ, Nava HR, Yendamuri S, LeVea CM, Nwogu CE, Groman A, Wilding G, Bain AJ, Hochwald SN, Khushalani NI. Outcomes of endoscopic resection for high-grade dysplasia and esophageal cancer. Surgical Endoscopy. Apr;28(4):1090-5, (2014)
  4. Hochwald SN et al. Decreasing morbidity and mortality in 100 consecutive minimally invasive esophagectomies. Surgical Endoscopy. 26, no. 1, pp. 162–167,(2012).
  5. Hochwald SN et al. Minimally Invasive Esophagectomy Is Safe and Effective Following Neoadjuvant Chemoradiation Therapy. Annals of Surgical Oncology. vol. 18, no. 12, pp. 3324–3329, (2011).