Selection of Operation for Esophageal Cancer Based on Staging

The concept of en bloc removal of tissue surrounding the esophagus was applied to intrathoracic esophageal cancers, and the first 80 cases were operated on by this technique between 1969 and 1981. Analysis of prognostic factors showed that only penetration through the esophageal wall and lymph node spread influenced survival. Since 1981, a new staging system based on wall penetration (W) and lymph nodes (N), as well as systemic metastases (M), and similar to the modified Dukes' system for colon cancer has been used to select patients before and during surgery for en bloc resection if favorable pathology (W1, N0, or N1) could be anticipated. When curative resection was not attainable, based on preoperative and operative staging, a standard esophagectomy was considered for relief of symptoms when necessary. From July 1981 to June 1984, 68 esophageal cancers were referred to us, and 31 were resected by the en bloc method, 21 by standard esophagectomy, and 16 were not resected. The success of preoperative staging was confirmed, as only nine of the 31 en bloc cases demonstrated both W2 and N2 pathology. The proportion of W2N2 cases subjected to en bloc esophagectomy was less (p < 0.01) than that in the preceding series. This selection of cases showed a favorable deviation in the survival curve following en bloc esophagectomy since 1981 compared to the earlier interval. Patients treated by en bloc esophagectomy had a significantly greater survival than they did following standard esophagectomy at all time intervals after 6 months. There was no difference in hospital mortality or complications between the two operations. Further evidence for the value of the new staging system was shown by the significant difference in survival curves between those with favorable versus unfavorable staging and treated by en bloc esophagectomy. Among all cases resected between 1981 and 1984, 18-month survival in W1 stage was 67% compared to 35% for W2 disease. Survival with NO disease was 58% versus 43% for N1 stage and 21% for N2 stage. The favorable survival rates after en bloc resection in those with limited (< W2N2) disease support the concept of selecting patients for curative surgery based on preoperative and operative staging. Preoperative radiation therapy caused a significant decline in patient survival at 6 and 12 months and has been abandoned. Adjuvant postoperative irradiation and/or chemotherapy was offered to all patients with W2, N1, N2, or M1 pathology and was accepted by approximately two thirds. There was no difference in the survival curves between those who did and did not accept postoperative therapy. However, in the patients with W2N2 disease, survival between 9 and 15 months was prolonged by approximately 6 months in those receiving postoperative treatment, and the difference approached statistical significance (0.1 > p > 0.5). Staging for esophageal cancer based on wall penetration and lymph node spread is valuable in determining prognosis and selection of treatment. For those with favorable staging, the use of en bloc resection for attempted cure has an acceptable mortality and an improved survival rate compared to those with the same stage disease treated by standard esophagectomy. En bloc resection appears particularly worthwhile in those with limited spread from the primary (W1N1 and W2N0). For those whose staging indicates little hope for prolonged survival, resection may be used for palliation of dysphagia and bleeding. Adjuvant therapy is still not a proven benefit, but trials should continue in patients with unfavorable disease.