Surgical Management of Midesophageal Carcinoma

Primary Surgical Approaches

The American Society of Clinical Oncology recommends radical transthoracic esophagectomy with en bloc two-field lymphadenectomy as the procedure of choice for fit patients with locally advanced resectable midesophageal cancer (cT2-T4a or cN1-3) 1
The National Comprehensive Cancer Network recommends the McKeown procedure, involving abdominal, right chest, and cervical access with reconstruction to the cervical esophagus, for midesophageal tumors specifically 1, 2
Surgery remains the backbone of curative-intent treatment for both squamous cell carcinoma (SCC) and adenocarcinoma (AC) of the esophagus, according to the European Society for Medical Oncology 1, 3

The Society of Surgical Oncology recommends minimally invasive esophagectomy (MIO) techniques, including robotics, over open approaches due to lower post-operative morbidity and improved quality of life 1, 2, 4
MIO results in quicker functional recovery, according to the American College of Surgeons 3
A population-based cohort study reported better long-term overall survival after MIO compared with open esophagectomy, as stated by the American Cancer Society 1
MIO is considered the surgical approach of choice in experienced centers, with a Level of evidence II, A, according to the National Cancer Institute 4

The American Society for Radiation Oncology recommends preoperative chemoradiotherapy (CRT) as standard of care for SCC of the esophagus 1, 2
Weekly carboplatin-paclitaxel combined with radiation (41.4 Gy in 23 fractions) followed by esophagectomy has shown improved survival compared to surgery alone, according to the European Society for Radiotherapy and Oncology 1
Pre- and perioperative treatment using chemotherapy or CRT increases rates of R0 resection (no tumor at margin) and improves survival rates, as stated by the Society of Surgical Oncology 5

The American Gastroenterological Association recommends endoscopic en bloc resection using either endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) for early-stage disease (T1a, N0, M0) 4, 7
Patients with involved deep endoscopic resection margins or significant risk factors for lymph node metastases should be offered further resective surgery with appropriate lymphadenectomy, according to the American College of Gastroenterology 3, 5

The National Comprehensive Cancer Network recommends surgical treatment for stages I and II (disease localized to the esophagus) 8, 9
Surgery remains an option for tumors extending beyond the esophageal wall (T3) or involving nodes (N1), according to the American Joint Committee on Cancer 8

Minimally invasive approaches have shown at least non-inferior oncological endpoints compared to open procedures, including free resection margins and lymph node yield, as stated by the Society of Surgical Oncology 3, 5
Close surveillance is essential after surgery, particularly in patients who had advanced disease, according to the American Cancer Society 4

The American College of Surgeons states that surgical quality assurance is critical, including credentialing of surgeons, standardization of technique, and monitoring of performance 7
The risk of pulmonary complications is higher with transthoracic approaches compared to transhiatal approaches, according to the European Respiratory Society 7
For cT2 N0 tumors, there is controversy regarding the need for preoperative treatment, and each case should be discussed by a multidisciplinary team, as recommended by the National Comprehensive Cancer Network 1, 2