Outcomes after surgery for esophageal cancer

Esophageal cancer is a virulent malignancy associated with a 5-year overall survival of approximately 5%. Treatment remains controversial-despite the results of prospective, randomized trials of combined-modality therapy-because results are poor with all strategies. The role of surgical resection in patients with esophageal cancer is controversial. The fact that most patients have advanced disease at the time of diagnosis makes surgery futile in the majority of cases. Nevertheless, surgery is the best option for cure in early-stage esophageal cancer and remains the superior modality for local control in locally advanced disease. The benefits and drawbacks of several surgical approaches are discussed in this review. Multiple factors are implicated in the etiology of postesophagectomy complications, the rate of which is quite high. Perhaps the most important contributor to morbidity and mortality after esophagectomy is the development of pulmonary complications. Over the past decade, there has been a trend toward the increased use of trimodality therapy in potentially operable patients-induction chemotherapy and radiation therapy, followed by surgery. The rationale for using induction therapy is that it allows simultaneous delivery of local (radiation therapy) and systemic (chemotherapy) modalities, provides for early tumor regression and symptom control, results in improved subsequent local control, and identifies responding patients who might benefit from adjuvant therapy. Thus, on the basis of recent studies and meta-analyses, there may be a modest survival advantage for patients who receive induction chemotherapy followed by surgery, compared with surgery alone. There is also an apparent increase in treatment-related mortality, mainly for patients receiving induction chemotherapy and radiotherapy. Currently, National Comprehensive Cancer Network guidelines support the use of induction therapy only in established clinical trial protocols.