Which patients are candidates for upfront esophagectomy?

Candidates for Upfront Esophagectomy in Esophageal Cancer

Upfront esophagectomy should be considered for all physiologically fit patients with early-stage (stage I or II) localized esophageal cancer, including T1-T3 tumors without bulky nodal involvement, who can tolerate major surgery. 1

Patient Selection Criteria

Appropriate Candidates for Upfront Surgery:

• Patients with early-stage disease (stage I or II) with tumors through T3 without bulky nodal involvement 1
• Physiologically fit patients able to tolerate general anesthesia and major thoracic/abdominal surgery 1
• Patients with localized resectable thoracic esophageal cancer >5cm from cricopharyngeus 1
• Patients with intra-abdominal esophagus or esophagogastric junction (EGJ) cancer 1
• Selected patients with stage III disease without involvement of adjacent critical structures 1
• Patients with T4 tumors with involvement limited to pericardium, pleura, or diaphragm 1

Contraindications to Upfront Surgery:

• Patients with cervical or cervicothoracic esophageal carcinomas <5cm from cricopharyngeus (should receive definitive chemoradiation) 1
• Patients with supraclavicular lymph node involvement 1
• Stage IV tumors with distant metastases or non-regional lymph node involvement 1
• T4 tumors with involvement of heart, great vessels, trachea, or adjacent organs (liver, pancreas, lung, spleen) 1
• Patients with clearly unresectable disease or severe comorbidities (cardiac/pulmonary disease) 1
• Patients with bulky, multistation nodal involvement (poor prognosis with surgery alone) 1

Preoperative Assessment

• Clinical staging should include EUS (with FNA if indicated), chest and abdomen CT scan, and PET scan (integrated PET/CT preferred) 1
• Laparoscopy should be considered for evaluation of resectability, especially for patients with large tumors involving the EGJ 1
• Nutritional assessment and support should be provided for patients with significant dysphagia and weight loss 1
• Multidisciplinary evaluation is essential for all patients with potentially resectable disease 1

Surgical Considerations

• Esophagectomy should be performed in high-volume centers by experienced surgeons 1, 2
• Lymph node dissection should aim to remove at least 15 lymph nodes for adequate staging in patients undergoing upfront surgery 1
• The surgical approach (transthoracic, transhiatal, or minimally invasive) depends on tumor location, size, and surgeon experience 1, 3
• For Siewert type I and II EGJ tumors, the surgical approach is similar to esophageal cancer, while type III tumors are treated as gastric cancers 1

Evidence-Based Considerations

• Recent evidence suggests that perioperative chemotherapy or neoadjuvant chemoradiotherapy may be preferable to upfront surgery for locally advanced disease 1
• The CROSS study and MAGIC trial showed significant survival improvements with preoperative therapy for resectable esophageal and EGJ cancers 1
• For clinical stage III disease, studies have shown mixed results comparing upfront surgery versus neoadjuvant approaches 4, 5
• Minimally invasive esophagectomy (MIE) may be associated with decreased morbidity and shorter recovery times compared to open procedures, particularly beneficial for older patients 1

Pitfalls and Caveats

• Lymph node involvement is a strong independent predictor of poor survival with surgery alone; these patients should be considered for multimodality therapy 1
• Open surgery should remain the standard for many patients, including those with previous abdominal surgery, large/bulky tumors, or when lymph node dissection may be difficult 1
• While MIE shows promising results, it remains investigational and requires surgeons with specific expertise 1
• Palliative resections should be avoided in patients with clearly unresectable disease or significant comorbidities 1
• For early-stage disease (T1a-T1b), endoscopic resection may be considered as an alternative to esophagectomy in selected cases 3, 6