eMedicine Specialties > Oncology > Carcinomas of the Gastrointestinal Tract

Esophageal Cancer: Follow-up

Author: Piero Marco Fisichella, MD, Assistant Professor of Surgery, Stritch School of Medicine, Loyola University; Director, Esophageal Motility Center, Loyola University Medical Center
Coauthor(s): Marco G Patti, MD, Professor of Surgery, Director, Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine
Contributor Information and Disclosures

Updated: Oct 24, 2009

Follow-up

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.

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.

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.
  • Anastomotic stricture may require dilatation (20%).
  • 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.

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% (Media file 7).
  • THE and TTE have equivalent survival rates.
  • Squamous cell carcinoma and adenocarcinoma, stage-by-stage, have equivalent survival rates.

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.

Miscellaneous

Special Concerns

  • Because most patients undergo surgery when lymph node metastases are already present, the 5-year survival rate for this disease remains quite low. Chemotherapy and radiotherapy (alone or in combination) have been used before or after surgery in the attempt to improve survival.
    • The aims of preoperative (neoadjuvant) chemotherapy are to reduce the bulk of the primary tumor before surgery to facilitate higher curative resection rates and to eliminate or delay the appearance of distant metastases. Note that chemotherapy concurrently administered with radiotherapy has demonstrated a pathologic response rate of as high as 30% but has been associated with increased operative morbidity and mortality. While chemotherapeutic management of squamous cell malignancies is generally based on cisplatin use, the chemotherapeutic choices in esophageal adenocarcinoma have been extrapolated from the chemotherapy experience in patients with adenocarcinoma of the stomach.
    • No completely satisfactory method is available to clinically stage esophageal cancer. The difficulty of clinically assessing the disease is reflected by the American Joint Committee staging system.
      • The 1983 staging system was based on the length of the intraluminal esophageal tumor, the presence of esophageal obstruction, and the involvement of palpable lymph nodes. This clinical staging system proved to be limited.
      • The 1988 revision now defines a clinical and pathologic staging system based entirely on the depth of esophageal wall invasion and the presence or absence of local nodal involvement. Neither of these parameters is assessed easily on a clinical basis.
      • To help overcome these problems Hofstatter proposed recently a modification of the American Joint Committee on Cancer (AJCC) nodal classification system to incorporate the number of involved lymph nodes with regional and nonregional node location. This seems to simplify and better predict long-term survival than does the current AJCC nodal system.
    • Conventional staging tools such as esophagoscopy or barium esophagogram can demonstrate only intraluminal disease extent, and CT scan of the chest is relatively insensitive, except for the presence of extensive local disease. Esophageal ultrasound allows the visualization of both the esophageal wall and local lymph nodes. As such, it allows a clinical determination of both T and N stage in most patients.
    • Previous reports of induction chemotherapy in esophageal cancer often are difficult to interpret because of varying definitions of response (eg, symptomatic improvement, decrease in tumor length after barium esophagram, subjective determination of improvement at endoscopy or CT scan). Even the complete response, often defined as endoscopic biopsies or cytologies with negative findings, is hampered by the inability to assess the true extent of the transmural disease. Not surprisingly, reported responses are quite variable, ranging from 20-65%, with clinical complete responses in as many as 40% of patients.
  • Neoadjuvant therapy consists of a combination of radiotherapy (approximately 45 Gy) and chemotherapy (cisplatin and 5-fluorouracil).
    • While the radiotherapy acts locally at the tumor site, the chemotherapy acts on tumor cells that have already spread. This combination therapy is usually administered over a 45-day period and is followed by esophageal resection after an interval of approximately 4 weeks.
    • The results of many studies suggest that approximately 15-20% of patients have a complete response to therapy because no tumor is found in the specimen by the pathologists; these patients have a definite improvement in survival. The remaining patients, in whom a partial response or no response has occurred, have no benefit.
      • A randomized trial conducted by Urba that compared preoperative chemoradiation (ie, cisplatin, fluorouracil, and vinblastine) versus surgery alone for patients with potentially resectable esophageal carcinoma did not demonstrate a statistically significant survival difference.
      • Walsh conducted a prospective randomized trial comparing surgery alone with combined chemotherapy, radiotherapy, and surgery and reported that patients who received induction chemotherapy (ie, 2 courses of cisplatin and fluorouracil, 1 course of radiotherapy at 40 Gy) followed by surgery had improved survival compared to those who had surgery alone. Of the patients who underwent surgery after multimodal therapy, 25% had complete responses as determined pathologically. Their median survival was 16 months, as compared with 11 months for those assigned to surgery alone. The survival advantage was even more evident at 3 years (32% vs 6%, P = .01).11
      • Bosset treated patients with induction chemoradiotherapy (ie, cisplatin and 18.5 Gy) and surgery and with surgery alone, reporting that in patients with squamous cell carcinoma of the esophagus, preoperative chemoradiotherapy did not improve overall survival, but it did prolong disease-free survival and survival deemed free of local disease.12
      • Herskovic reported that combined therapy increased the survival of patients with squamous cell carcinoma or adenocarcinoma of the esophagus, stages T1-3 N0-1 M0, compared with radiotherapy alone.8
      • A recent meta-analysis of randomized trial data identified 10 randomized comparisons of neoadjuvant chemoradiotherapy versus surgery alone (n=1209) and 8 trials of neoadjuvant chemotherapy versus surgery alone (n=1724) in patients with local operable esophageal carcinoma. The authors found that the hazard ratio for all-cause mortality with neoadjuvant chemoradiotherapy versus surgery alone was 0.81 (95% CI 0.70-0.93; p=0.002), corresponding to a 13% absolute difference in survival at 2 years, with similar results for different histological tumor types: 0.84 (0.71-0.99; p=0.04) for squamous-cell carcinoma (SCC), and 0.75 (0.59-0.95; p=0.02) for adenocarcinoma. The hazard ratio for neoadjuvant chemotherapy was 0.90 (0.81-1.00; p=0.05), which indicates a 2-year absolute survival benefit of 7%. There was no significant effect on all-cause mortality of chemotherapy for patients with SCC (hazard ratio 0.88 [0.75-1.03]; p=0.12), although there was a significant benefit for those with adenocarcinoma(0.78[0.64-0.95]; p=0.014). The authors concluded that significant survival benefit was evident for preoperative chemoradiotherapy and, to a lesser extent, for chemotherapy in patients with adenocarcinoma of the esophagus.
    • The goal for the future is to identify patients who are likely to benefit from neoadjuvant therapy.
  • Adjuvant therapy does not appear to improve survival. No survival benefit is obtained when radiation and chemotherapy are administered postoperatively.
  • 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 (Media file 1).
    • 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%.
 


More on Esophageal Cancer

Overview: Esophageal Cancer
Differential Diagnoses & Workup: Esophageal Cancer
Treatment & Medication: Esophageal Cancer
Follow-up: Esophageal Cancer
Multimedia: Esophageal Cancer
References
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Further Reading

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Keywords

esophageal cancer, esophagus cancer, Barrett epithelium, Barrett's epithelium, Barrett esophagus, Barrett's esophagus, gastrointestinal reflux disease, GERD, esophageal adenocarcinoma, esophagus adenocarcinoma, esophagus carcinoma, esophageal carcinoma, reflux disease, squamous cell carcinoma

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Contributor Information and Disclosures

Author

Piero Marco Fisichella, MD, Assistant Professor of Surgery, Stritch School of Medicine, Loyola University; Director, Esophageal Motility Center, Loyola University Medical Center
Piero Marco Fisichella, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Society for Surgery of the Alimentary Tract, and Society of American Gastrointestinal and Endoscopic Surgeons
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.

Medical Editor

Philip Schulman, MD, Chief, Medical Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center; Clinical Professor, Department of Medicine, New York University School of Medicine
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: celgene Honoraria Speaking and teaching; Amgen Honoraria Speaking and teaching; genetech/idec Honoraria Speaking and teaching

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Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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.

CME Editor

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
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Chief Editor

Jules E Harris, MD, Clinical Professor of Medicine, Division of Hematology/Medical Oncology, Department of Internal Medicine, University of Arizona College of Medicine at Tucson; Consulting Staff, 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
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