What are the recommended surgical options for midesophageal (esophageal) carcinoma?

Surgical Options for Midesophageal Carcinoma

For midesophageal carcinoma, the McKeown procedure (abdominal, right chest, and cervical access with reconstruction to the cervical esophagus) is the recommended surgical approach in fit patients, with minimally invasive esophagectomy (MIO) techniques preferred due to lower post-operative morbidity and improved quality of life. 1

Primary Surgical Approaches

Standard Surgical Techniques

• Radical transthoracic esophagectomy with en bloc two-field lymphadenectomy is the procedure of choice for fit patients with locally advanced resectable midesophageal cancer (cT2-T4a or cN1-3) 1
• For midesophageal tumors specifically, the McKeown procedure is recommended, involving abdominal, right chest, and cervical access with reconstruction to the cervical esophagus 1
• Surgery remains the backbone of curative-intent treatment for both squamous cell carcinoma (SCC) and adenocarcinoma (AC) of the esophagus 1

Minimally Invasive Approaches

• Minimally invasive esophagectomy (MIO) techniques, including robotics, are now preferred over open approaches 1
• Three randomized controlled trials have shown that MIO results in:
  • Lower post-operative morbidity
  • Quicker functional recovery
  • Better quality of life up to 1 year after surgery 1
• A population-based cohort study from Sweden and Finland reported better long-term overall survival after MIO compared with open esophagectomy 1
• MIO is considered the surgical approach of choice in experienced centers [Level of evidence II, A] 1
• Hybrid minimally invasive esophagectomy (combining laparoscopy with open thoracotomy) has shown lower incidence of major complications, particularly pulmonary complications, compared to fully open procedures 2

Preoperative and Perioperative Considerations

Neoadjuvant Therapy

• Preoperative chemoradiotherapy (CRT) is recommended as standard of care for SCC of the esophagus 1
• Weekly carboplatin-paclitaxel combined with radiation (41.4 Gy in 23 fractions) followed by esophagectomy has shown improved survival compared to surgery alone 1
• Five-year overall survival rate of >60% for SCC in the trimodality arm is substantially higher than with surgery alone or definitive CRT 1
• Pre- and perioperative treatment using chemotherapy or CRT increases rates of R0 resection (no tumor at margin) and improves survival rates 1

Alternative Approaches

• Definitive CRT with surveillance and salvage esophagectomy when needed is also a recommended option for SCC 1
• For patients who cannot tolerate surgery or where the tumor is in the cervical esophagus, definitive CRT is recommended 1

Special Considerations

Early-Stage Disease

• For early-stage disease (T1a, N0, M0), endoscopic en bloc resection using either endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) is preferred 1
• Patients with involved deep endoscopic resection margins or significant risk factors for lymph node metastases should be offered further resective surgery with appropriate lymphadenectomy 1

Patient Selection

• Surgical treatment is recommended for stages I and II (disease localized to the esophagus) 1
• Surgery remains an option for tumors extending beyond the esophageal wall (T3) or involving nodes (N1) 1
• Surgery is not recommended for tumors involving mediastinal organs (T4) or with distant metastases (M) 1
• In frail patients, less extensive procedures may be considered, though with less extensive lymphadenectomy 1

Outcomes and Follow-up

• Minimally invasive approaches have shown at least non-inferior oncological endpoints compared to open procedures, including:
  • Free resection margins
  • Lymph node yield
  • Overall survival 1, 2
• Hybrid minimally invasive esophagectomy has demonstrated:
  • Better postoperative nutritional status
  • Lower inflammatory markers
  • Shorter hospital stays compared to open procedures 3
• Close surveillance is essential after surgery, particularly in patients who had advanced disease 1

Pitfalls and Caveats

• Surgical quality assurance is critical, including credentialing of surgeons, standardization of technique, and monitoring of performance 2
• The risk of pulmonary complications is higher with transthoracic approaches compared to transhiatal approaches 1
• For cT2 N0 tumors, there is controversy regarding the need for preoperative treatment, and each case should be discussed by a multidisciplinary team 1
• Minimally invasive techniques require specialized training and experience to achieve optimal outcomes 1, 2