|Year : 2011 | Volume
| Issue : 1 | Page : 34-39
Eight-year experience in esophageal cancer surgery
B Thakur1, Chun Shan Zhang2, Xian Li Meng3, S Bhaktaman1, S Bhurtel1, P Khakural1
1 Department of Surgical Oncology, BP Koirala Memorial Cancer Hospital, Bharatpur, Nepal
2 Xingtai City Cancer Hospital, China
3 Ist Hebei Cancer Hospital, China
|Date of Web Publication||10-Feb-2011|
Department of Surgical Oncology, BP Koirala Memorial Cancer Hospital, Bharatpur
Source of Support: None, Conflict of Interest: None
Aim: Esophageal cancer remains a major and lethal health problem. In Nepal, not much has been explored about its management. The aim of this study was to conduct a retrospective review of esophageal cancer patients undergoing surgery or combined modality treatment at a cancer hospital in Nepal. Materials and Methods: Resectable cases were treated primarily with surgery. Locally advanced cases with doubtful or obviously unresectability underwent preoperative chemo/radiation or chemoradiation followed by surgery. Results: Among 900 patients, 103 were treated with curative intent. Mean age of patients was 54 years, and 100% of the patients presented with complaint of dysphagia. Surgery as a single modality of treatment was done in 57% of cases, and the remaining underwent combined modality treatment. Transthoracic and transhiatal approaches were used in 95% and 5% of cases, respectively. Nodal sampling, two-field (2-FD), and three-field lymphadenectomy (3-FD) were done in 18%, 59%, and 20% of cases, respectively. A majority of patients had pathological stage III disease (46.6%). In-hospitality mortality was 5%, and anastomotic leakage rate was 14%. In 87% of patients, R0 resection was achieved. Overall, 4-year survival was 20%. A R0 resection, early-stage disease and 3-FD favored the survival advantage (P < 0.05). Conclusion: The mortality, complication, and survival results were in the acceptable range. R0 resection and radical nodal dissection should be standard practice.
Keywords: Esophageal cancer, extended esophagectomy, lymph node dissection, three-field lymph node dissection
|How to cite this article:|
Thakur B, Zhang CS, Meng XL, Bhaktaman S, Bhurtel S, Khakural P. Eight-year experience in esophageal cancer surgery. Indian J Cancer 2011;48:34-9
| » Introduction|| |
Esophageal cancer constitutes a major health problem. It is the ninth most common type of cancer worldwide. It is endemic in many parts of the developing nations. 
High prevalence areas include Asia, southern and eastern Africa as well as northern France. , In the US, esophageal cancer is infrequent, constituting 1% of all malignancies. Approximately 16,470 new cases of esophageal carcinoma and 14,280 deaths are estimated to occur in 2008 in the US. 
At diagnosis, nearly 50% of patients have cancer that extends beyond the locoregional confines of the primary. Fewer than 60% of patients with locoregional cancer can undergo a curative resection. Nearly 70%-80% of the resected specimens harbor metastases in the regional lymph nodes. Thus, clinicians are often dealing with advanced-stage carcinoma in newly diagnosed patients. 
There has been increased enthusiasm toward the use of multimodality treatment protocols in the management of esophageal cancer, though convincing evidence in their favor has yet to be established. For the resectable and operable cases, surgery still remains the standard treatment. The 5-year survival after an R0 resection is disappointing, varying from 15% to 20%. Not much has been explored about its management in Nepal. The aim of this study was to conduct a retrospective review of esophageal cancer patients undergoing surgery or combined modality treatment at our Hospital.
| » Materials and Methods|| |
A retrospective review of all the patients (ECOG: 0-2), who were diagnosed with esophageal cancer, underwent complete blood count, serum chemistry profile, coagulation profile, pulmonary function test, stair climbing test, echocardiography (selected cases), and CT chest including abdomen. On the basis of CT, it was decided whether the case is early-stage (resectable) disease or locally advanced (T3-4 as per CT findings of doubtful plane of tumor with the adjacent organ or definite evidence of adjacent organ invasion, bulky mediastinal nodes or excisable coeliac nodes). Patients with early-stage (resectable cases) disease were surgically operated on. Locally advanced cases underwent various treatment modalities: chemotherapy (ct), radiation therapy (rt), or chemoradiation (ctrt) prior to surgery. The decision was dependent on the treating oncologist. Three weeks after completion of neoadjuvant treatment, patients were reassessed with chest computed tomography (CT) and, if there was a response, they were surgically operated on. Any patient with obvious T4 lesion and no response to preoperative treatment or any patient with tracheo-esophageal fistula or stage IVb disease were excluded. Surgical approach also varied, but a 5-cm tumor-free margin was attempted to achieve always. Both the transhiatal (THE) and transthoracic (TTE) approaches were used. In the last 2 years, we always performed two-incision right TTE (Ivor-Lewis) or three-incision right TTE (McKeon) esophagectomy. Nodal dissection varied from simple sampling to standard two-field (2-FD) or, in recent years, three-field (3-FD) lymphadenectomy. Patients with R1/R2 resections received postoperative chemoradiation. Some patients after curative R0 resection also received chemotherapy. Patients were followed up for 28-48 months. Statistical analysis was done using SPSS 16.0 software. Numerical values were compared using t-test or F test. Categorical variables were compared using Chi-square test. Kaplan-Meier method was used to draw the survival analysis. Log-rank test was used for the comparison of survival curves. P < 0.05 was considered significant.
| » Results|| |
In the last eight years of establishment of our hospital, about 900 patients of esophageal cancer were diagnosed and treated at this hospital. Because of late stage and/or poor performance status, only 103 patients could undergo radical surgery either alone or in combination with chemotherapy and/or radiation therapy.
Some of the basic parameters, blood profile, and complaints at presentation are presented in [Table 1],[Table 2], and [Table 3], respectively.
A total of 33 patients (32%) had some associated illness [Table 4]. Various details of treatment and complications are presented in [Table 5],[Table 6],[Table 7],[Table 8],[Table 9]. In 16 patients (15.5%), some accessory organs were resected [Table 7].
Mean tumor length was 6 cm, mean intraoperative blood loss was 526 ml, and mean intraoperative blood transfusion was 427 ml. In 100% cases, stomach was used for reconstruction. The anastomotic leak as mentioned in the Table was 14.3%, but all leaks occurred from the anastomosis placed at the neck. There was no leak from the anastomosis placed in the chest (P=0.035). On analyzing only the neck anastomoses, the leak rates were found to be 12.7% (6 of 47 cases, excluding three postoperative deaths), and they were done in single layer in 50 cases and in double layers in 30 cases. On separately analyzing these two techniques, there was a leak rate of 18% (9 leaks in 50 cases) and 27% (8 leaks in 30 cases) in single and double layer technique, respectively (P = 0.141).
Tumor location, final pathological report, and final pathological UICC stage are presented in [Table 10],[Table 11], and [Table 12], respectively.
R0 resection could be achieved in 90 cases (87.4%). In 5 (4.9%) and 8 cases (7.8%), R1 and R2 resections were achieved, respectively. Of these R1 and R2 resections, proximal margin was positive in 3 cases (2.9%), whereas in majority (9.7%), axial margin was positive. All cases of proximal positive resections margins had cervical esophageal location of the tumor.
Because of poor follow-up, only a complete survival data of 59 patients are available, with median overall survival of 20 months and overall 4-year survival of 20%. Survival curves comparing various factors are shown in [Figure 1],[Figure 2],[Figure 3],[Figure 4].
A total of 17 patients with locally advanced lesions (cT3-4N1) underwent preoperative chemoradiation, followed by surgery. In this group, the postoperative mortality rate was 6% (1 of 17) and the anastomotic leakage rate was 35.3%. A complete pathological response could be achieved in 31% of cases. Kaplan-Meier estimates have been shown in [Figure 5].
| » Discussion|| |
At diagnosis, most esophageal carcinomas are in an advanced stage; thus, surgery is inappropriate in 40-60% of patients, mainly because of the inability to resect incurable nodes, the presence of distant metastases, or the high operative risk.  The approach to esophageal surgery for cancer is controversial. There are surgeons who prefer to not open the chest at all and favor transhiatal approach only. And there are others who prefer transthoracic approach.
From our results, it is obvious that a minority of patients could undergo curative surgery because of poor general condition or advanced stage of disease. Smoking and excessive use of hot beverages appear to be associated with esophageal malignancies. Exclusive presentation with dysphagia in all and a loss of weight of 9 kg at presentation show that patients seek the medical advice at a late stage.
The long-term survival rate of patients who have undergone esophagectomy remains low. A collected review of 83,783 patients treated between the years 1953 and 1978 showed that the overall 5-year survival referred for surgery was only 4%.  Another review of 43,692 patients treated between the years 1980 and 1988 showed only a marginal improvement in 5-year survival (4-10%).  In an attempt to improve the surgical results, preoperative (neoadjuvant) and postoperative (adjuvant) multimodal treatments are used. But the reviews showed that this has only minimal impact on survival. Therefore, among the various treatment modalities, surgery remains the mainstay for the treatment of patients with potentially curable disease.
Middle third location of the tumors (52%) and squamous histology (84%) were common in our study. Therefore, McKeon's esophagectomy had to be done in most of the cases (68.9%), though with a higher risk of anastomotic leakage. Single-layer (Gambee stitches) technique appears to decrease the rate of leakage, though it was not statistically significant (P = 0.141).
There have been considerable inconsistencies in the management of esophageal cancer at our hospital. Surgery as a single modality was applied in 57% of patients. Most cases had stage III disease. The overall 4-year survival of 20% in our study is satisfactory and comparable to other series, considering that a majority of patients (46.6%) had pathological stage III disease and not even a small group (17.5%) had pathological stage IV disease. Early-stage disease favored the survival advantage. Stage I disease had a 4-year survival of 100%, stage II had 4-year survival of approximately 40%, whereas no patients with stage IV disease survived 4 years. R0 resection should be always our goal and R1/R2 resection should always be avoided. We achieved a significant survival difference in favor of R0 resection (P = 0.000). All cases with positive proximal resection margin had cervical location of tumor. Moreover, if we analyze only tumors of cervical esophagus, out of 4 cases, 3 had positive proximal margin. Therefore, it may be concluded that surgery may not be wise for this location of tumors. A group of patients (16%), who had locally advanced (T3-4N1) disease, underwent preoperative concurrent chemoradiation followed by surgery. The postoperative mortality rate was 6%, complete pathological response 31%, and 4-year survival appeared promising (18%).
Lymph node involvement is an important prognostic indicator in esophageal carcinoma, and treatment failure is mostly related to locoregional recurrence, including nodal recurrence. The lymphatic channels of the esophagus run vertically along the axis of the esophagus, and some of them drain into the cervical lymph glands upwards and into the abdominal glands downwards. Therefore, it is logical to conclude that not only the mediastinal lymph nodes but also the cervical and upper abdominal groups of lymph nodes are part of the regional lymphatic drainage. Metastatic deposits in these nodes should not be considered as distant metastases.  However, the approach to the nodes still remains controversial. It varies from simple sampling to 2-FD and 3-FD nodal dissection. A nationwide study in Japan showed that the rate of lymph node metastasis was 27.4% in the cervical nodes, 55.8% in the mediastinal nodes, and 43.8% in the abdominal nodes.  The incidence of lymph node metastasis surrounding the recurrent laryngeal nerve is 26.7-48.6%. A review on the 3-FD showed the operative mortality lying between 0% and 3.7% and, similarly, morbidity varied from 37.7% to 46.7%. The rate of anastomotic leakage was 19-30%.  A number of researchers in Japan reported an excellent overall 5-year survival, varying from 30.8% to 55%. Again a nationwide study showed a better 5-year survival (34.3%) following 3-FD compared with that (26.7%) following 2-FD (P < 0.001).  Our results also show a significant survival advantage in favor of 3-FD in comparison with 2-FD or sampling (P = 0.000).
From this retrospective study, we could retrieve several observations and conclusions:
- Patients attend to the hospital at advanced stage of disease
- People who prefer smoking and having excessive hot beverages seem at risk of esophageal cancer
- Virtually 100% patients attend with dysphagia
- Early stage is the single most important prognostic factor
- For locally advanced disease, combined modality treatment gives promising results
- Best results have been achieved after 3-FD. Therefore, 3-FD or at least 2-FD should be considered standard practice.
Clearly, the major limitation of the study was its retrospective nature and lack of endoscopic ultrasound (EUS) and positron emission tomography (PET) scan for proper pretreatment staging of the tumor. We would like to call the surgeons and oncologists to initiate some randomized trials, including the multimodality treatment, and to make a national protocol in order to avoid the differences in the treatment.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]
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