Esophageal Carcinoma

This is a difficult, confusing and frustrating subject. By the time most patients with esophageal carcinoma present, they are unresectable, although esophageal resection for cure in early esophageal carcinoma is possible and should be done. There are many alternatives to management and we will present our philosophy and approach, and then present the alternatives.

Tumors should be divided into cervical esophageal carcinoma, mid-thoracic esophageal carcinoma and lower esophageal carcinoma. The management of these lesions differs, as does their prognosis. The fundamental questions to ask in any tumor of the esophagus is: Is the lesion resectable and is the patient a surgical candidate who can survive a major operation, (i.e. these are the same questions to ask in lung carcinoma or in fact carcinoma in any portion of the body).

To evaluate whether the lesion is resectable, clinical staging of esophageal carcinoma is necessary. This is according to the TNM system. A T-1 lesion does not extend through to the muscle wall; a T-2 lesion does. A T-3 lesion extends outside the muscle wall. Lymph nodes are N-1 (unilateral), N-2 (bilateral) or N-3 (extensive and multiple). The M system is either, M-0 or M-1, i.e. visceral metastases or involvement of distant nodes (i.e. cervical or celiac).

Stage I is a T-1 lesion; Stage II is a T-2 lesion; Stage III is a T-3 lesion or involvement of lymph nodes without metastatic lesions. These are generally considered inoperable. The management of Stage I and Stage II esophageal carcinoma is controversial, and the role of preoperative radiation therapy is likewise controversial. There is some evidence that radiation therapy prior to resection of esophageal carcinoma improves disease free survival, although an overall improvement in survival has yet to be conclusively demonstrated. The gastric nodes should be considered as N-1 lymph nodes, rather than distant node metastases.

The other important issue is the patient as a surgical candidate. These patients generally are malnourished because of difficulty eating and may require a period of hyperalimentation to improve their nutritional status to make them a proper surgical candidate. It is important to evaluate their lung function so that it will be established that they can survive an operation without postoperative total ventilator dependence and that they can be weaned from a ventilator. Other co-morbid conditions need to be evaluated since these people generally are smokers who have concomitant lung carcinoma, emphysema or bronchitis, or may have other vascular complications related to their smoking; i.e. peripheral vascular disease including carotid, aortic and lower extremity vasculopathy, as well as coronary artery disease.

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