Elsevier

The Lancet Oncology

Volume 4, Issue 8, August 2003, Pages 481-488
The Lancet Oncology

Review
The role of surgery in the management of oesophageal cancer

https://doi.org/10.1016/S1470-2045(03)01167-7Get rights and content

Summary

In the absence of medical contraindications to surgery, resection is the mainstay of treatment for localised oesophageal cancer. Advancements in preoperative staging and imaging, anaesthesia delivery, surgical technique, and postoperative care, now enable the surgeon to safely operate on patients with oesophageal tumours and to tailor the procedure on the basis of performance status, tumour location, and extent of disease. During the past 10 years, several “minimally invasive” techniques, which aim to limit the extent of resection, have been introduced; these procedures are currently being investigated for use in both staging and treatment of oesophageal malignant diseases. Despite these accomplishments however, overall 5-year survival remains disappointing: less than 25% of patients live for 5 years after oesophagectomy. For patients with locally or regionally advanced disease (stage IIa, IIb, III, and IVa), combining several treatment approaches, either with or without surgery, can result in good objective responses and, in some patients, durable survival. The role of surgery in such combined modality approaches is still evolving and some investigators have challenged its worth. To provide a definitive review of the issues involved, we outline the types of surgery used to treat cancer of the oesophagus and summarise the available data about their effectiveness. Clinical outcomes, the value of preoperative chemo-radiotherapy, and the use of surgery are all considered.

Section snippets

Extent of surgery

There is considerable debate about whether modification of operative techniques, eg, reducing radicality or residual disease, can substantially change the outcome. Issues which remain particularly controversial are the optimum surgical approach, the extent of lymph-node dissection, and the value of using minimally invasive techniques.

Surgery as part of combined modality therapy

The equivalence between incidence and mortality rates in the USA for oesophageal cancer4 and the failure of surgery alone to alter this pattern means that many oncologists favour combined modality therapy. As a consequence, chemo-radiotherapy, either with or without surgery, is the most widely used treatment for patients with oesophageal cancer in the USA.57 We have chosen to critically analyse the data from available clinical trials to find out whether this trend in treatment is justified or

Definitive chemoradiotherapy

The traditional role of surgery in the management of oesophageal cancer has further been challenged by the results of a phase III trial examining the usefulness of definitive chemoradiotherapy. In RTOG 8501,72 patients were randomised to receive chemoradiotherapy or radiotherapy alone; neither treatment group underwent surgery. The results imply that chemoradiotherapy is superior to radiotherapy—26% of patients in the combined modality group were alive at 5 years compared with no patients who

Conclusions

The management of oesophageal cancer will undoubtedly continue to evolve as improvements in technology, combined with a greater understanding of genomics and biology of tumours, better define effective therapeutic interventions and allow introduction of novel treatments into strategies for clinical management. The role of surgery is likely to change over time, but will continue as a primary, or secondary, treatment modality for a substantial number of patients with oesophageal cancer. In

Search strategy and selection criteria

References for this review were identified by searches of PubMed. Search criteria included the terms “esophageal neoplasm”, “esophagectomy”, “transhiatal”, “transthoracic”, “minimally invasive surgery”, “laparoscopy” or “laparoscopic”, “thoracoscopy” or “thoracoscopic”, “radiotherapy”, “chemotherapy”, “chemoradiotherapy”, and “multimodality therapy”. Selected papers from the search results were retrieved and only papers involving human studies, published in English, were used for this review.

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