with Dr. Sara Nogueira
Esophageal cancer is the ninth most common cancer and the sixth most common cause of cancer death worldwide.
The esophagus is a long structure, about 40cm long, that connects the pharynx to the stomach, allowing the ingested food to move forward.
Surgically, it is divided in 3 segments: cervical, thoracic and abdominal.
Histologically, the esophagus has 4 layers, from mucosa to adventitia. The Muscularis externa is divided in two layers, a circular one and a longitudinal layer.
Given the lack of serosa, the close relationship with the surrounding structures, and its vague symptoms, esophageal cancer is often diagnosed in advanced stages.
There are 2 major histologic subtypes of esophageal cancer: squamous cell carcinoma (SCC) and adenocarcinoma (AC). Each histologic subtype has distinct clinicopathologic and demographic characteristics.
SCC is more commonly seen worldwide and is predominantly found in Far Eastern countries, with an incidence that has been declining in the recent decades. It has greater predilection for the proximal esophagus and is generally associated with tobacco smoking, alcohol consumption, and low socioeconomic status.
By contrast, there has been a significant increase in the prevalence of AC, which is more frequently seen in Western countries. The major risk factors for the development of AC include gastroesophageal reflux disease and the presence of Barrett’s esophagus.
Early esophageal cancer is defined as carcinoma contained within the superficial components of the epithelial lining and with no lymph node involvement.
Following the AJCC/TNM classification, it is classified into stage 0 and stage I (T1-2N0) cancer and it includes Barrett’s neoplasia.
There are currently 3 treatment options for Early Esophageal Cancer: Endoscopy, Radiation and Surgery, each with its pros and cons.
Endoscopy is the gold standard for esophageal cancer diagnosis and can be used as default treatment in patients with early stage disease. There are 3 technical options to choose: Endoscopic Mucosal Resection (EMR), Endoscopic Submucosal Dissection (ESD) and Mucosal Ablation.
Chemoradiation has established itself as the preferred neoadjuvant treatment for locally advanced disease. Its efficacy was proven in many randomized controlled trials that also showed a high percentage of pathological complete response (15% - 55%). The use of chemoradiation as definitive treatment is currently reserved for patients with unresectable disease, patients who are poor surgical candidates and patients who refuse surgery. An RCT with 71 patients with T1N0 cancer showed that chemoradiation as a definitive treatment did not reduce disease-free survival and overall survival.
Surgery is the cornerstone of multimodality management of esophageal cancer and the final treatment option in cases of failure of a conservative approach. The 2 most commonly performed types of esophagectomy are: the transthoracic esophagectomy, or Ivor-Lewis esophagectomy of ; and McKeown total esophagectomy.
Although highly effective, it is important to remember that an esophagectomy, no matter the technique chosen, has a morbidity rate that can reach 75% and a mortality rate that cannot be ignored. That is why it is so important to have more studies and more data supporting the use of non-surgical options to treat early esophageal cancer.
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