Current status of preoperative treatment for carcinoma of the esophagus.

Abstract

carcinoma of the esophagus continues to be a lethal malignancy in the vast majority of patients in whom it is diagnosed. The 1985 Surveillance Epidemiology and End Result report from the National Cancer Institute suggested that the 5-year survival rate for all patients presenting with esophageal cancer was 6%.’ Although this is due at least in part to delayed diagnosis in most individuals, the anatomy and pathophysiology of this tumor also contribute to this poor prognosis. Esophageal cancer is known to spread longitudinally through the submucosal lymphatics and to disseminate in the extraesophageal lymph nodes in the cervical, abdominal, and intrathoracic areas. Lateral extension of esophageal carcinoma often involves vital organs and structures that preclude curative resection, and distant metastatic spread, though infrequent at time of presentation, removes any chance for cure by surgery alone. In an attempt to improve results, two differing strategies have been used for the treatment of esophageal carcinoma. One strategy involves increasing the extent of dissection by performing radical esophagectomy with en bloc lymph node dissection. This “en bloc” esophagectomy has been championed by Skinner who, despite significant operative morbidity and mortality, has not produced superior 5-year survival figures when comparing his approach to a standard esophagectomy.2,3 Esophagectomy combined with radical lymph node dissections in the neck, thorax, and abdomen have been espoused by several Japanese thoracic surgeons who feel this approach decreases local recurrence and improves 5-year survival.4-6 The second strategy involves preoperative treatment using radiotherapy, chemotherapy, or a combination of both and has been termed “neoadjuvant” therapy. The intent of this approach is to reduce tumor size, enhance resectability, and sterilize any microscopic local tumor extension so that better local control might be achieved. Neoadjuvant therapy may also improve regional tumor control by sterilizing micrometastases in the areas of lymphatic drainage. Finally, it is hoped that systemic treatment modalities will allow for ablation of microscopic metastatic disease, thus minimizing the chance for distant metastatic recurrence. The majority of adjuvant therapy protocols involve preoperative treatment for a number of reasons. Preoperative therapy ensures an adequate vascular supply for the tumor, which is important both to assure adequate delivery of chemotherapeu