Surgical staging and surgical treatment in esophageal cancer

Esophageal cancer is the fastest growing malignancy in the United States. Surgery remains the standard primary treatment but overall survival for all patients undergoing primary surgery is dismal. This is thought to be secondary to the advanced stage in many patients at the time of diagnosis. The presence or absence of metastatic lymph nodes is indeed the single most important prognosticator. Current preoperative staging includes computerized tomography, magnetic resonance imaging, and transesophageal ultrasound. The limitations of each of these techniques are well known. Preoperative thoracoscopy and laparoscopy staging is emerging as a safe, effective, and accurate way of staging patients with esophageal cancer. Moreover, it may become important in allocating treatment, as it may be used to individualize radiation therapy fields, or to allocate bimodality or trimodality therapy to patients in trials, depending on the results of pretreatment lymph node sampling. Future trials in esophageal cancer should consider the results of pretreatment pathologic staging in allocating patients to appropriate modalities of therapy.