eMedicine Specialties > Oncology > Carcinomas of the Gastrointestinal Tract

Esophageal Cancer: Treatment & Medication

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

Treatment

Medical Care

Nonoperative therapy is usually reserved for patients who have esophageal carcinoma and are not candidates for surgery. The goal of therapy for these patients is palliation of dysphagia, allowing them to eat. A single best method of palliation cannot be applied to every situation. Most patients require more than one palliative method to sustain lumen patency during the course of their disease.

  • The most appropriate method to control dysphagia should be tailored for each patient individually, depending on tumor characteristics, patient preference, and the specific expertise of the physician. The following treatment modalities are available to help achieve this goal:
    • Chemotherapy as a single modality has limited use. Only a few patients achieve a modest and short-lived response.
    • Radiation therapy is successful in relieving dysphagia in approximately 50% of patients. In patients with advanced esophageal cancer, the preoperative combination of chemotherapy and radiotherapy has shown good results. In a large multicenter study, Herskovich and colleagues reported a 2-year survival rate of 38%, with a median survival of 12.5 months.8 See the practice guideline Combined Modality Radiotherapy and Chemotherapy in Nonsurgical Management of Localized Carcinoma of the Esophagus.9
    • Laser therapy (Nd:YAG laser) can help achieve temporary relief of dysphagia in as many as 70% of patients. Multiple sessions are usually required to keep the esophageal lumen patent.
    • Patients may be intubated with expandable metallic stents, which can be deployed by endoscopy under fluoroscopic guidance and can keep the esophageal lumen patent. They are particularly useful when a tracheoesophageal fistula is present.
    • In 2006, a Cochrane review tried to assess the effectiveness of chemotherapy versus best supportive care or different chemotherapy regimens against each other, in metastatic esophageal carcinoma. The authors found that there was no consistent benefit of any specific chemotherapy regimen.10 Chemotherapy agents with promising response rates and tolerable toxicity are cisplatin, 5-fluorouracil (5-FU), paclitaxel, and anthracyclines. Future trials comparing palliative treatment modalities should assess quality of life with validated quality of life measures.
  • Photodynamic therapy (PDT) offers an interesting nonsurgical form of therapy.
    • PDT refers to the administration of photosensitizing chromophores, which are selectively retained by dysplastic malignant tissue. Light is delivered in the area where the photons are absorbed by the photosensitizer. The photosensitizer becomes photoexcited and transfers its energy to a chemical substrate that causes biologic damage to the abnormal tissue.
    • Recent studies have demonstrated that PDT alone or with Nd:YAG laser thermal ablation combined with long-term acid inhibition provides an effective endoscopic therapy to (1) eliminate Barrett mucosal dysplasia and superficial esophageal cancer and (2) reduce the extent of and, in some cases, eliminate Barrett mucosa. A drawback of PDT is the formation of esophageal strictures in 34% of patients. Therefore, even though the initial results are encouraging, this form of treatment is still considered experimental.

See related CME at Highlights in Head and Neck Cancer.

Surgical Care

Esophageal resection (esophagectomy) remains a crucial part of the treatment of esophageal cancer. It is used in patients who are considered candidates for surgery. It no longer is used for palliation of symptoms because other treatment modalities are now available for relieving dysphagia (see Medical Care). An esophagectomy can be performed by using an abdominal and a cervical incision with blunt mediastinal dissection through the esophageal hiatus (ie, transhiatal esophagectomy [THE]) or by using an abdominal and a right thoracic incision (ie, transthoracic esophagectomy [TTE]).

  • THE offers the advantage of avoiding a chest incision, which can be a prolonged cause of discomfort and can further aggravate the condition of patients with compromised respiratory function.
    • After removal of the esophagus, continuity of the gastrointestinal tract is usually reestablished using the stomach.
    • Some authors have questioned the validity of THE as a cancer operation because part of the operation is not performed under direct vision and fewer lymph nodes are removed compared to TTE. However, many retrospective and 2 prospective studies have shown no difference in survival between the operations, suggesting that the type of operation is not the factor influencing survival but, rather, the stage of the cancer at the time the operation is performed.
    • The morbidity associated with the operation is due mostly to cardiac, respiratory, and septic complications. As with other complex operations (eg, cardiac operations, resection of the pancreas or liver), a low mortality rate is achieved in centers with personnel who have more clinical experience (ie, those in high-volume centers). The better results (as compared to low-volume centers) are due to a team approach, during which expert surgeons work with intensivists, cardiologists, pulmonologists, radiologists, and nurses who have experience and expertise. For instance, in California from 1990-1994, only 5 centers had a mortality rate of 5% or less for esophageal resection for cancer, while the average mortality rate in the state was approximately 18%.
  • Relevant anatomy includes the following:
    • The esophagus is a muscular tube that extends from the level of the 7th cervical vertebra to the 11th thoracic vertebra. The esophagus can be divided into 3 anatomic parts: the cervical esophagus, the thoracic esophagus, and the abdominal esophagus.
    • The blood supply of the cervical esophagus is derived from the inferior thyroid artery, while the blood supply for the thoracic esophagus comes from the bronchial arteries and the aorta. The abdominal esophagus is supplied by branches of the left gastric artery and inferior phrenic artery.
    • Venous drainage of the cervical esophagus is through the inferior thyroid vein, while the thoracic esophagus drains via the azygous vein, the hemiazygous vein, or the bronchial veins. The abdominal esophagus drains through the coronary vein.
    • The esophagus is characterized by a rich network of lymphatic channels in the submucosa that can facilitate the longitudinal spread of neoplastic cells along the esophageal wall. Lymphatic drainage is to cervical nodes, tracheobronchial and mediastinal nodes, and gastric and celiac nodes.
  • Indications for surgery include the following:
    • Diagnosis of esophageal cancer must be made in a patient who is a candidate for surgery.
    • Surgery is indicated when high-grade dysplasia is present in a patient with Barrett esophagus. As many as 50-70% of such patients are found to have cancer when the esophagus is resected.
  • Contraindications to surgery include the following:
    • Metastasis to N2 nodes (ie, celiac, cervical, or supraclavicular lymph nodes) or solid organs (eg, liver, lungs) is a contraindication.
    • Invasion of adjacent structures (eg, recurrent laryngeal nerve, tracheobronchial tree, aorta, pericardium) is a contraindication.
    • Severe associated comorbid conditions (eg, cardiovascular disease, respiratory disease) can decrease a patient's chances of surviving an esophageal resection.
    • Cardiac function and respiratory function are carefully evaluated preoperatively. A forced expiratory volume in 1 second of less than 1.2 L and a left ventricular ejection fraction of less than 0.4 are relative contraindications to the operation.
  • TTE involves the following:
    • The patient is placed supine on the operating room table. An arterial line, a central venous catheter, a Foley catheter, and a dual-lumen endotracheal tube are placed. Preoperative antibiotics are administered. An upper midline incision is made.
    • After exploring the peritoneal cavity for metastatic disease (if metastases are found, the operation is not continued), the stomach is mobilized. The right gastric and the right gastroepiploic arteries are preserved, while the short gastric vessels and the left gastric artery are divided.
    • Next, the gastroesophageal junction is mobilized, and the esophageal hiatus is enlarged. A pyloromyotomy is performed, and a feeding jejunostomy is placed for postoperative nutritional support.
    • After closure of the abdominal incision, the patient is repositioned in the left lateral decubitus position and a right posterolateral thoracotomy is performed in the fifth intercostal space.
    • The azygos vein is divided to allow full mobilization of the esophagus. The stomach is delivered into the chest through the hiatus and is then divided approximately 5 cm below the gastroesophageal junction.
    • An anastomosis (hand-sewn or stapled) is performed between the esophagus and the stomach at the apex of the right chest cavity. Then, the chest incision is closed.
  • THE involves the following:
    • Preoperative details are similar to those of TTE, with the exception of a single rather than a double-lumen endotracheal tube. The neck is prepared in the operative field.
    • The abdominal part of the operation is identical to the TTE; however, dissection of the esophagus is performed through the enlarged esophageal hiatus without opening the right chest. The esophagus is mobilized in this fashion all the way to the thoracic inlet.
    • Then, a 6-cm incision is made in the left side of the neck. The internal jugular vein and carotid artery are retracted laterally, and the esophagus is identified and isolated posterior to the airway. To prevent injury to the left recurrent laryngeal nerve, no mechanical retractors are used to retract the trachea.
    • Next, after resection of the proximal stomach and thoracic esophagus, the remaining stomach is pulled up through the posterior mediastinum until it reaches the remaining esophagus at the cervical level.
    • Then, a hand-sewn anastomosis is performed, and a small drain is placed in the neck alongside the anastomosis. The abdominal and neck incisions are closed.
  • Advantages of minimally invasive surgery include the following:
    • The use of laparoscopic or thoracoscopic techniques has revolutionized the treatment of benign esophageal disorders such as achalasia and GERD.
    • When compared to open surgery, the hospital stay is shorter, the postoperative discomfort is reduced, and the recovery time is much faster. In the near future, these techniques might find a place in the treatment of esophageal cancer, reducing the morbidity due to cardiac and respiratory complications.

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

Pharmacy Editor

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
Disclosure: Nothing to disclose.

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
Disclosure: GlobeImmune Salary Consulting; Amplimed Consulting fee Consulting; FibroGen Consulting fee Consulting

 
 
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