Surgical Intervention for Esophageal Cancer

Key Principles

The National Comprehensive Cancer Network (NCCN) recommends that esophageal squamous cell carcinoma (ESCC) can be definitively treated with chemoradiotherapy alone without surgery in responding patients, whereas esophageal adenocarcinoma (EAC) requires surgical resection as part of multimodality therapy when feasible 1
Approximately 50% of ESCC patients achieve complete pathologic response after chemoradiotherapy, meaning surgery may not provide additional benefit in these complete responders 2, 1
For ESCC patients who demonstrate clinical complete response to chemoradiotherapy, definitive chemoradiotherapy without surgery is an acceptable definitive treatment 2, 1
EAC patients should receive either preoperative chemoradiotherapy or perioperative chemotherapy, both followed by surgical resection 1

Upper-aerodigestive tract endoscopy is required for ESCC staging to evaluate potential synchronous head and neck primaries 3, 4, 5
Laparoscopy is recommended for locally advanced (T3/T4) adenocarcinomas of the esophagogastric junction to rule out peritoneal metastases 3, 4, 5

At least 16-18 and preferably 20 lymph nodes should be dissected and examined, with adequate nodal dissection within appropriate nodal fields (abdominal and thoracic) 1
Transthoracic esophagectomy with two-field lymph node resection is recommended for intrathoracic ESCC 6

Two equivalent options exist for adenocarcinoma: preoperative chemoradiotherapy or perioperative chemotherapy (FLOT regimen preferred) 1
Preoperative chemoradiotherapy is the standard approach when surgery is planned for squamous cell carcinoma 1

Postoperative complications may be more severe with chemoradiotherapy compared to chemotherapy alone 1
The addition of radiation therapy is expected to be more beneficial when surgery is less optimal or less extensive 2, 1
Adequate quality surgery requires clear surgical margins and adequate nodal dissection 1