Esophageal Cancer

Each year, approximately 17,000 new cases of esophageal cancer are diagnosed. By the time most patients notice symptoms, the disease is locally advanced. Patients with localized disease have a 5-year survival rate of about 35%; fortunately, cure rates are substantially higher than this for stage I and early stage II tumors. In recent years, there has been a trend towards increased incidence of adenocarcinoma (one of the subtypes of esophageal cancer), arising at the gastroesophageal junction (where the stomach meets the esophagus). This is now the most common type of esophageal cancer in the United States. It tends to develop in those who have the changes of  "Barrett's esophagus" in their lower esophagus, resulting from chronic reflux of stomach acid into the lower esophagus.  

Of all operations in which the association between surgical volume and outcomes (surgical results) has been studied, esophagectomy (removal of all or part of the esophagus) is the operation for which the data is clearest that the procedures should be performed at high volume medical centers with the greatest expertise and skills, such as at Stanford Health Care.

Stanford is the highest volume and highest quality esophagectomy center in the San Francisco Bay Area. Stanford thoracic surgeons have performed 40-60 esophagectomies per year for each of the past several years. There has only been one postoperative death in the past 100 esophagectomies, and our combined morbidity/mortality outcomes, as reported by the Society of Thoracic Surgeons, place our results in the top 15% of those hospitals who choose to report their results (mainly major centers of excellence). We consider excellence in the surgical management of esophageal cancer, along with management of lung cancer, to be at the core of the mission of the Thoracic Surgery service at Stanford.

You will be treated at Stanford by thoracic surgeons who have received extensive, specialized training in the surgical management of esophageal cancer at some of the top medical centers in the country and who have continued since training to accumulate broad esophageal experience. We work together with oncologists, radiation oncologists, pathologists, and radiologists at the Stanford Cancer Center to provide a comprehensive approach to the treatment of esophageal carcinoma. Dr. Joseph Shrager is a surgical esophageal cancer specialist who is specially trained to perform esophagectomy with the lowest risk and the greatest chance of cure.

Patients with esophageal cancer may first notice symptoms such as difficulty swallowing food or liquids, weight loss, and/or abdominal pain. Patients may have a history of gastroesophageal reflux disease (GERD) and Barrett's esophagus, which are known risk factors for the development of esophageal cancer. This latter group often has an early-stage tumor identified at routine endoscopy during follow-up for Barrett's esophagus, in the absence of symptoms. Patients with difficulty swallowing should be referred for endoscopy. If an upper endoscopy shows evidence of a tumor, it will be biopsied. The most common type of esophageal cancer in the United States is adenocarcinoma. The second most common form is squamous cell carcinoma. Once esophageal cancer is established, the patient should be promptly referred to a thoracic surgeon for further evaluation and management.

At Stanford, we believe it is critical to completely assess the stage or extent of the spread of esophageal cancer – both in the immediate vicinity of the tumor and to other parts of the body – to determine the optimal form of therapy. A Chest and Abdomen CT (CAT) scan will identify the location and size of the esophageal tumor as well as any enlarged lymph nodes in the thorax or upper abdomen. A Positron Emission Tomography (PET) scan will give us important information about whether there is any metastatic spread of the esophageal cancer to regional lymph nodes or to distant sites, such as the liver, bone, or lung. In most patients, we will also recommend an Endoscopic Ultrasound (EUS) to determine how deep the esophageal tumor has penetrated the wall of the esophagus and to provide further information about local lymph nodes. Lymph nodes that are in close proximity to the esophagus can often be needle-biopsied at the time of EUS.

The presence or absence of esophageal cancer in the lymph nodes and the depth of tumor invasion into the esophageal wall are very important. Chemotherapy and radiation therapy are often given prior to esophagectomy in patients in whom the cancer has spread to the lymph nodes or has deeply penetrated the esophageal wall, and the surgical approach chosen may also vary based upon these findings. Once the diagnosis of esophageal cancer is established and the staging tests are completed, therapy can be initiated.

At Stanford, the treatment of esophageal cancer is comprehensive and involves a collaborative effort between oncologists, radiation oncologists, pathologists, and radiologists. Patients with early stage esophageal tumors may be treated by surgical removal of the tumor by the thoracic surgeon alone;  however, patients with more advanced stage tumors will be treated in collaboration with either local medical and radiation oncologists or with our multidisciplinary team at the Stanford GI Oncology Tumor Board.

Common stage-based therapies are as follows. These will vary depending on detailed tumor and patient characteristics – this is a very simplified version of the esophageal cancer staging system:

• Stage 0 (carcinoma in situ) or high-grade dysplasia – Tumor confined to the mucosa (the most superficial, inner layer of the esophageal wall) – Mucosal ablative therapies such as endoscopic mucosal resection and/or radiofrequency ablation; or transhiatal or "minimally invasive" esophagectomy
• Stage I – Tumor has extended no further than the outer layer of the esophageal wall, and it has not spread to lymph nodes – Surgery alone (esophagectomy) – often by the transhiatal or "minimally invasive" approach
• Stage II – Tumor has usually extended into the outer 2 layers of the esophagus and/or has spread to 1-2 lymph nodes – Surgery alone; surgery followed by chemotherapy with or without radiotherapy; or chemoradiation followed by surgery
• Stage III – Tumor has usually extended beyond the esophageal wall as well as into surrounding lymph nodes – Chemoradiation followed by surgery
• Stage IV – Tumor has spread to other parts of the body – Usually chemotherapy alone

Esophagectomy is the surgical removal of the lower two-thirds or nearly the entirety of the esophagus, along with the uppermost part of the stomach, and all of the surrounding lymph nodes. The stomach is then reshaped into a "new esophagus," brought up into the chest or the neck, and reconnected to the remaining portion of the esophagus (Figures 1-6).

The operation is technically challenging and can result in high mortality and morbidity if performed by less experienced surgeons who perform only a few esophagectomies per year. The thoracic surgeons at Stanford perform between 40 and 60 esophagectomies per year with exceptional outcomes. We perform all of the various, available esophagectomy techniques at Stanford, depending upon patient factors and the particular tumor's location, stage, and extensiveness:

• Ivor Lewis Esophagectomy: the esophageal tumor is removed through an abdominal incision and a right thoracotomy (a surgical incision of the chest wall). The esophagogastric anastomosis (reonnection between the stomach and remaining esophagus) is located in the upper chest.
• Transhiatal Esophagectomy: the esophageal tumor is removed through abdominal incision, without thoracotomy, and a left neck incision. The esophagogastric anastomosis is located in the neck. This procedure may also be considered "minimally invasive" as compared with #1 and #3.
• "Three Incision Esophagectomy": the esophageal tumor is removed through an abdominal incision, right thoracotomy, and left neck incision. The esophagogastric anastomosis is located in the neck.
• Minimally Invasive Esophagectomy: the esophageal tumor is removed through small abdominal incisions and small incisions in the right chest (thoracoscopy). The esophagogastric anastomosis is located in the upper chest as in the "open" Ivor Lewis technique (#1, above). Read more about Minimally Invasive Esophagectomy below.

The nursing staff on the thoracic surgical wards at Stanford is experienced and very knowledgeable in the postoperative care of patients who undergo esophagectomy, further enhancing patient recovery.

The broad experience and highly specialized training of Stanford's thoracic surgeons allows them to offer comprehensive and high quality surgical care for patients with esophageal cancer. We have achieved outstanding surgical outcomes for esophageal cancer, making us a center of excellence for the treatment of this disease.

Esophagectomy at most medical centers is performed exclusively via open incisions in both the chest and the abdomen, meaning that the ribs are spread apart and the abdominal wall is widely opened. This results in more discomfort and possibly prolonged recovery times. At Stanford, however, totally laparoscopic and thoracoscopic esophagectomy allows thoracic surgeons in some cases to perform a standard "Ivor Lewis"-type esophagectomy through five small abdominal incisions and 3 to 4 right VATS (thoracoscopy) incisions (Figures 1-6). The abdominal cavity and the right thoracic cavity are directly viewed with a tiny, 10 mm, video camera that is placed through one of the small incisions. Minimally invasive esophagectomy is a particularly good option (along with transhiatal esophagectomy, which also avoids thoracotomy), for patients with earlier stage tumors, as well as for elderly patients and patients with moderate lung disease who have a somewhat higher risk for complications.