Limited surgery for 'early' cancer of the esophagus

Abstract

BACKGROUND: Early squamous cell carcinoma and early adenocarcinoma of the esophagus are potentially curable diseases. Limited surgical procedures are carried out as alternatives to either endoscopic mucosectomy or to radical esophagectomy for T1 esophageal cancer. In this stage the only indication for limited surgery with curative intent is in patients who have no evidence of lymph node metastasis as the procedure is not comprising an adequate lymphadenectomy. The depth of tumor infiltration into the mucosal and submucosal layers is correlated with the rate of nodal metastases and therefore with long-term prognosis. The crucial point is to define the right stage of T1 carcinoma for this type of therapy. METHODS: A review of the literature was performed to gather published data concerning the status of limited surgery for 'early' cancer of the esophagus. RESULTS: For mucosal esophageal cancer endoscopic mucosal resection is an alternative treatment option but requires intensive follow-up since the rate of complete resections is lower than in limited and in radical surgical procedures. On the other hand, low postinterventional morbidity and functional integrity of the tubular esophagus support the indication of endoscopic mucosal resection for mucosal cancer. The Merendino procedure may offer another option in the treatment of early esophageal cancer. Major advantages of this operation over endoscopic mucosectomy include the possibility of complete resection of the carcinoma and the entire Barrett segment. The lower postoperative morbidity and mortality compared to radical surgery are in favour of the Merendino resection. Vagal-sparing esophagectomy is another surgical option in esophageal cancer limited to the mucosa. However, both limited procedures are not appropriate in case of lymph node metastases. None of these techniques have been validated in prospective clinical studies. CONCLUSION: Procedures with limited radicality are technically feasible but should strictly be reserved for patients with mucosal cancer. Results of limited surgery should be validated in clinical studies compared to radical esophagectomy comparing functional and prognostic outcome.