Surgical management of esophageal malignancy

Esophageal carcinoma is a highly lethal disease with increasing prevalence and an equally dramatic epidemiologic shift. Its causal association with gastroesophageal reflux disease and adenocarcinoma of the esophagus is well established, and the molecular events underlying this progression from mucosal injury to metaplasia to dysplasia to carcinoma are now becoming clear. Current diagnostic modalities and preoperative staging systems have significant limitations. The extent of surgical resection for esophageal carcinoma remains controversial. Disease confined to the mucosa and submucosa is more common, and endoscopic ablative techniques have been proposed. However, preoperative evaluation of tumor depth and regional nodal metastases remains inadequate in these very early lesions and urges caution before adoption of therapies that may compromise cure. Patients with disease confined to the mucosa or submucosa should undergo resectional therapy aimed at removing the entire esophageal wall, including the periesophageal and perihiatal lymph nodes. For disease penetrating the submucosa, the extent of surgical therapy must be tailored to the objectives of treatment (cure vs palliation) and preoperative stage. Although data from seven prospective, randomized trials are encouraging, no clear survival benefit has been documented for neoadjuvant combined-modality therapy. Surgical resection remains the standard of care and best chance for cure in the treatment of esophageal malignancy, with combined-modality therapy reserved for prohibitive surgery candidates.