Esophageal Cancer Follow-up

  • Author: Fernando AM Herbella, MD, PhD, TCBC; Chief Editor: Jules E Harris, MD   more...
 
Updated: Mar 6, 2012
 

Further Inpatient Care

The average length of postoperative hospital stay is 9-14 days.

Patients usually spend the first postoperative night in the intensive care unit (ICU).

Patients can be extubated immediately after the operation, but mechanical ventilation should be continued if any concerns about the respiratory status are present. Respiratory complications (eg, atelectasis, pleural effusion, pneumonia) and cardiac complications (eg, cardiac arrhythmias) usually occur in the first postoperative days.

Patients leave the ICU and are transferred to the surgical ward only when their respiratory status and cardiac status are satisfactory.

Feeding through the feeding jejunostomy begins on postoperative day 1.

On postoperative day 6, a swallow study is performed to check for anastomotic leakage. If no leak is present, patients start oral feedings. If a leak is present, the drainage tubes are left in place and nutrition is provided entirely through the feeding jejunostomy until the leak closes spontaneously.

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Further Outpatient Care

Approximately 85-90% of patients go home after discharge. The remaining patients may need additional time in a skilled nursing facility if they live alone and if they cannot take care of themselves.

Patients are seen by the responsible surgeon at 2 weeks and 4 weeks after discharge from the hospital and subsequently every 6 months by an oncologist.

Most patients return to their regular level of activities within 2 months.

GERD may lead to esophageal cancer.

Because most esophageal cancers today are adenocarcinomas that originated from Barrett esophagus, stopping the sequence of events leading from GERD to adenocarcinoma is now possible (see the image below).

Cascade of events that lead from gastroesophageal Cascade of events that lead from gastroesophageal reflux disease to adenocarcinoma.

Better control of gastroesophageal reflux can prevent the development of Barrett metaplasia in patients with GERD and the development of high-grade dysplasia in patients with metaplasia.

Endoscopic follow-up evaluations should be performed at 1- to 2-year intervals to detect the presence of high-grade dysplasia, allowing intervention before cancer develops.

Follow-up of patients with Barrett esophagus includes the following:

For metaplasia, the common recommendation is to perform routine endoscopy every 12-24 months because no evidence suggests that either medical or surgical therapy can stop the progression to high-grade dysplasia and cancer. In addition, routine endoscopy can detect a tumor at an early stage, thereby increasing the possibility of a curative resection.

For high-grade dysplasia, the protocol suggested by investigators at the University of Washington in Seattle proposes endoscopy every 3 months with jumbo forceps and 4-quadrant biopsy samples taken at 1-cm intervals. The rationale is to avoid esophagectomy in patients who will not progress to cancer, based on the belief that this protocol will identify carcinoma in situ before it becomes invasive with lymph node metastases. This protocol has 2 major problems, as follows:

The protocol can rarely be followed in the average clinical practice, that is, outside of tertiary care centers, because of poor patient compliance and reluctance by the gastroenterologists to perform such extensive biopsies. In addition, there is a risk of missing an in situ lesion. Once the tumor is invasive, lymph node metastases are common and the chance of cure is lost.

When an esophagectomy is performed for high-grade dysplasia detected using endoscopy, adenocarcinoma is found in approximately 40% of cases (range of 30-73%).

Based on these considerations, the authors and others strongly recommend that esophagectomy be performed once high-grade dysplasia is detected. The operation must be performed by experienced surgeons in high-volume centers in order to keep the mortality rate at less than 5%.

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Complications

Complications occur in approximately 40% of patients.

Respiratory complications (15-20%) include atelectasis, pleural effusion, and pneumonia.

Cardiac complications (15-20%) include cardiac arrhythmias and myocardial infarction.

Septic complications (10%) include wound infection, anastomotic leak, and pneumonia.

Surgical complications are represented mainly by anastomotic leaks and stricture that may require dilatation (20%). Modernly, leaks may be treated with endoscopic placement of self-expanding removable plastic stents.[30]

The mortality rate depends on the functional status of the patient and the experience of the surgeon and the team taking care of the patient. A mortality rate of less than 5% should be the goal for esophagectomy for cancer. With rare exceptions, this mortality rate is usually achieved only in tertiary care centers.

An intrathoracic leak following esophagectomy is a known tragic complication of the procedure that can lead to sepsis and death. A retrospective review of 1223 esophagectomies for cancer showed that modern surgical management of intrathoracic leaks results in no increased mortality and has no impact on long-term survival.

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Prognosis

Survival depends on the stage of the disease. Lymph node metastases or solid organ metastases are associated with low survival rates.

A recent report of 1085 patients who underwent THE for cancer showed that the operation was associated with a 4% operative mortality rate and a 23% 5-year survival rate. A subgroup of patients with a better 5-year survival rate (48%) was identified. These patients received preoperative radiation and chemotherapy (ie, neoadjuvant therapy), with complete response (ie, disappearance of the tumor).

The overall 5-year survival rate for esophageal cancer remains approximately 20-25% for all stages. Patients without lymph node involvement have a significantly better prognosis and 5-year survival rate compared to patients with involved lymph nodes. Stage IV lesions are associated with a 5-year survival rate of less than 5%.

THE and TTE have equivalent survival rates.

Squamous cell carcinoma and adenocarcinoma, stage-by-stage, have equivalent survival rates.

A study by Suzuki et al found that higher initial standardized uptake value (SUV) is associated with poorer overall survival among patients with esophageal or gastroesophageal carcinoma receiving chemoradiation. The authors suggest that positron emission tomography (PET) may become useful in randomized trials and for individualizing therapy.[31] A study by Gillies et al also found that the use of PET-CT scanning to predict survival is effective. The presence of fluorodeoxyglucose (FDG)-avid lymph nodes was an independent adverse prognostic factor.[32]

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Patient Education

For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education article, Cancer of the Esophagus.

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Contributor Information and Disclosures
Author

Fernando AM Herbella, MD, PhD, TCBC  Affiliate Professor, Attending Surgeon in Gastrointestinal Surgery, Esophagus and Stomach Division, Department of Surgery, Federal University of Sao Paulo, Brazil; Private Practice; Medical Examiner, Sao Paulo's Medical Examiner's Office Headquarters, Brazil

Fernando AM Herbella, MD, PhD, TCBC is a member of the following medical societies: Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Coauthor(s)

Marco G Patti, MD  Professor of Surgery, Director, Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine

Marco G Patti, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Gastroenterological Association, American Medical Association, American Surgical Association, Association for Academic Surgery, Pan-Pacific Surgical Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Southwestern Surgical Congress, and Western Surgical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Philip Schulman, MD  Chief, Medical Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center

Philip Schulman, MD, is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, American Society of Hematology, and Medical Society of the State of New York

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Wendy Hu, MD  Consulting Staff, Department of Hematology/Oncology and Bone Marrow Transplantation, Huntington Memorial Medical Center

Wendy Hu, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Blood and Marrow Transplantation, American Society of Hematology, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Rajalaxmi McKenna, MD, FACP  Southwest Medical Consultants, SC, Department of Medicine, Good Samaritan Hospital, Advocate Health Systems

Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis

Disclosure: Nothing to disclose.

Chief Editor

Jules E Harris, MD  Clinical Professor of Medicine, Section of Hematology/Oncology, University of Arizona College of Medicine, Arizona Cancer Center

Jules E Harris, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association of Immunologists, American Society of Hematology, and Central Society for Clinical Research

Disclosure: GlobeImmune Salary Consulting

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Endoscopy demonstrating intraluminal esophageal cancer.
Cascade of events that lead from gastroesophageal reflux disease to adenocarcinoma.
Barium swallow demonstrating stricture due to cancer.
Barium swallow demonstrating an endoluminal mass in the mid esophagus.
Chest CT scan showing invasion of the trachea by esophageal cancer.
Transhiatal esophagectomy in which (a) is the abdominal incision, (b) is the cervical incision, and (c) is the stomach stretching from abdomen to the neck.
Five-year survival for esophageal cancer based on TNM stage.
Table. Staging Classification.
Stage IAT1N0M0
Stage IBT2N0M0
Stage IIAT3N0M0
Stage IIBT1,T2N1M0
Stage IIIAT4aN0M0
T3N1M0
T1,T2N2M0
Stage IIIBT3N2M0
Stage IIICT4aN1,N2M0
T4bAny NM0
Any TN3M0
Stage IVAny TAny NM1
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