Review

Surgery for oesophageal cancer

The role of surgery in the management of

oesophageal cancer
Peter C Wu and Mitchell C Posner

In the absence of medical contraindications to surgery,

resection is the mainstay of treatment for localised
oesophageal cancer. Advancements in preoperative staging
and imaging, anaesthesia delivery, surgical technique, and
postoperative care, now enable the surgeon to safely
operate on patients with oesophageal tumours and to tailor
the procedure on the basis of performance status, tumour
location, and extent of disease. During the past
10 years, several minimally invasive techniques, which aim
to limit the extent of resection, have been introduced; these
procedures are currently being investigated for use in both
staging and treatment of oesophageal malignant diseases.
Despite these accomplishments however, overall 5-year
survival remains disappointing: less than 25% of patients
live for 5 years after oesophagectomy. For patients with
locally or regionally advanced disease (stage IIa, IIb, III, and
IVa), combining several treatment approaches, either with or
without surgery, can result in good objective responses and,
in some patients, durable survival. The role of surgery in
such combined modality approaches is still evolving and
some investigators have challenged its worth. To provide a
definitive review of the issues involved, we outline the types
of surgery used to treat cancer of the oesophagus and
summarise the available data about their effectiveness.
Clinical outcomes, the value of preoperative chemoradiotherapy, and the use of surgery are all considered.
Lancet Oncol 2003; 4: 48188

During the past two decades, an epidemiological shift has

occurredadenocarcinoma has surpassed squamous-cell
carcinoma as the most common histological type of
oesophageal cancer in both the USA and western Europe.14
These countries have also experienced a parallel increase in
the incidence of gastro-oesophageal reflux disease and
development of Barretts metaplasia;5,6 the frequency, severity,
and duration of reflux symptoms correlate with an increased
risk of oesophageal adenocarcinoma.7 Furthermore, owing to
the link between obesity and reflux disease, the increasing
prevalence of obesity in the USA may also be contributing to
the climbing incidence of oesophageal adenocarcinoma.810
This alarming increase has made therapeutic management of
oesophageal carcinoma an urgent issue. The question of
which treatment approach is the most appropriate is much
debated, but since the number of well-controlled prospective
randomised trials is small, efforts to resolve this controversy
have been mostly unsuccessful.
Resection is still standard treatment for patients with
localised oesophageal cancer who do not have medical
contraindications to surgery (figure 1). Advances in nonTHE LANCET Oncology Vol 4 August 2003

Figure 1. Transhiatal oesophagectomy. The oesophagus and mobilised

stomach are delivered from the abdominal cavity. The tumour can be
visualised in the distal oesophagus (top). The resected portion shows an
ulcerated oesophageal adenocarcinoma (bottom).

invasive imaging, preoperative staging, anaesthesia, and

postoperative pain control, combined with refinements in
surgical technique and postoperative care, have enabled
experienced centres to reduce operative mortality rates to
below 5%.1113 There are various techniques for attempting
curative resection of oesophageal cancer and surgery has
traditionally been viewed as the most effective way of ensuring
both locoregional control and long-term survival. Therefore,
extending the limits of resection (ie, use of radical
PCW is a Surgical Oncology Fellow in the Department of Surgery,
University of Chicago, IL, USA. MCP is a Professor of Surgery and
Chief of Surgical Oncology in the Department of Surgery, University
of Chicago, IL, USA.
Correspondence: Prof Mitchell C Posner, Department of Surgery,
University of Chicago, 5841 S. Maryland Avenue,
MC 5031, Chicago, IL 60637, USA. Tel: +1 773 834 0156.
Fax: +1 773 702 0564. Email: mposner@surgery.bsd.uchicago.edu

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481

Review

Surgery for oesophageal cancer

Table 1. Randomised controlled trials comparing transthoracic (TTE) with transhiatal (THE) oesophagectomy
N

Pulmonary
complications

Anastamotic leak (%) Postoperative

mortality (%)

Median survival
(months)

5-year survival (%)

Ref

TTE

THE

TTE

THE

TTE

THE

TTE

THE

TTE

THE

TTE

THE

114

106

57

27

<0001

16

14

NS

NS

24

216

NS

39

29

NS

23

19

20

N/A

N/A

N/A

N/A

N/A

N/A

NS

135

16

NS

N/A

N/A

N/A

24

16

16

50

25

N/A

125

125

NS

63

63

NS

N/A

N/A

NA

N/A

N/A

N/A

25

35

32

20

19

NS

NS

86

63

NS

12.0

16

NS

N/A

N/A

N/A

26

N/A, not applicable; NS, non significant

procedures) is considered reasonable for improving overall trends associated with the role of surgery in the management
outcome. Proponents of en bloc oesophagectomy with of carcinoma of the oesophagus, and provide guidelines for
extended lymphadenectomy claim lower recurrence rates and survival intervention in multimodality treatment strategies.
For the purposes of this paper, we define carcinoma of the
increased survival in patients with locally and regionally
advanced lesions.1417 However, few appropriately designed oesophagus as tumours of the gastro-oesophageal junction
clinical trials have examined the effectiveness of this approach either with or without Barretts changes. Tumours of the
compared with less radical procedures. There have been gastric cardia are a separate entity not specifically addressed
consistent reports of median survival times of 1224 months here, although the determination of site of origin of lesions in
and 5-year survival of less than 25% for patients who undergo this region is often not possible. We recognise that
oesophagectomy alone. These results prompted a re- adenocarcinoma and squamous-cell carcinoma of the
evaluation of the role of surgical resection for oesophageal oesophagus are disparate diseases and, therefore, should be
cancer. Critics argue that if the extent of surgery is not the addressed with separate treatment. Unfortunately, this
most crucial determinant of survival, then more patient distinction has been blurred in most trials so both histological
friendly approaches should be used. A recent development is types are generally studied and managed in a similar way.
the use of minimally invasive techniques, which incorporate Where possible and appropriate, we have noted the
thoracoscopic or laparoscopic manoeuvers, for both the histological types being assessed. Our recommendations are
staging and treatment of oesophageal malignant diseases. weighted towards the management of adenocarcinoma of the
Theoretically, these procedures should provide equivalent middle and distal oesophagus, because this pathological entity
outcomes to radical surgery and reduce postoperative is most common in the USA.
morbidity, mortality, and length of stay in hospital. However,
prospective
randomised
trials
of
preoperative Extent of surgery
chemoradiotherapy have not definitively shown that this There is considerable debate about whether modification of
approach has benefits over surgery alone. High rates of operative techniques, eg, reducing radicality or residual
objective tumour response with chemoradiotherapy (25% disease, can substantially change the outcome. Issues which
complete response and 6070% partial
pathological response) suggest that
surgery may now be considered an
adjuvant treatment. This view has been
reinforced by trial results indicating that
the proportion of patients who survive
for 5 years after receiving chemoradiation
without surgery is comparable to that
reported with surgery alone.18 As a
consequence, many investigators and
clinicians have begun to question the
necessity of surgical intervention.
Less invasive methods of treatment,
for example, endoscopic oesophageal
stent placement and photodynamic or
laser therapy, are now being used instead
of surgery for relief of the symptoms of
dysphagia in the palliative setting.1922 This
development provides the impetus for
oncologists to question the role of
resection in oesophageal cancer and to
challenge the use of surgical intervention
in this disease. In this review, we aim to Figure 2. Extent of lymph node dissection for a standard esophagectomy (left) and for a threedescribe the concepts, issues, data, and field lymphadenectomy.

482

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Review

Surgery for oesophageal cancer

remain particularly controversial are the optimum surgical

approach, the extent of lymph-node dissection, and the value
of using minimally invasive techniques.
Transthoracic vs transhiatal resection

The two most common surgical approaches for curative

resection of oesophageal cancer are transthoracic (TTE) and
transhiatal (THE) oesophagectomy. Proponents of TTE claim
it gives direct visualisation and thorough dissection of
perigastric/perioesophageal nodal tissue and thoracic
oesophagus thereby ensuring complete tumour removal and
minimising the potential for occult residual disease and
tumour spillage. The direct transthoracic approach
substantially reduces the risk of injury to adjacent structures
including the azygos vein, thoracic duct, aorta, and bronchus.
However, supporters of THE claim that it is oncologically
equivalent (with a similar poor outcome) to TTE, minimises
respiratory complications, reduces the lethal complications of
mediastinitis due to anastamotic leakage, and shortens the
duration of the operation leading to decreased morbidity and
mortality.
Four randomised controlled trials comparing the
outcome of patients who underwent TTE or THE have been
published (table 1).2326 Three of these phase III trials2426 had
very small sample sizes so no definitive conclusions can be
drawn from their data. In all three trials, postoperative
morbidity and mortality rates were similar for both groups
and overall survival was unaffected by choice of surgical
approach. A fourth trial from the Netherlands23 involved
220 patients with adenocarcinoma of the mid or distal
oesophagus who were randomly assigned to undergo either
TTE or THE. Significantly more lymph nodes were dissected
from patients in the TTE group (31 vs 16, p <0001); however,
there was no difference between the groups in terms of how
radical the procedures were: the numbers of R0, R1, and R2
resections were equivalent. A significantly higher incidence of
pulmonary complications, and increased time in both
intensive-care unit and hospital were recorded for patients
who underwent the transthoracic approach, but there was no
difference in postoperative mortality between the two
procedures. At a median follow-up of 47 years there were no
significant differences in survival, for median, 5-year diseasefree, overall, and quality-adjusted values. The investigators
noted a trend toward improvements in disease-free and
overall survival benefit at 5 years with TTE; the survival curves
began to separate at 3 years.
In addition, two meta-analyses27,28 reviewing over
65 studies published between 1986 and 1999 that compared
TTE and THE have been published. Both series concluded
that overall perioperative complications and survival at 3 or 5
years did not differ significantly between transthoracic and
transhiatal procedures. There was a significantly higher
perioperative mortality rate for patients who underwent TTE
whereas those patients treated wtih THE had a higher
incidence of anastamotic leak, anastamotic stricture, and
recurrent laryngeal nerve injury.
Mortality rates varied considerably between the two
procedures from 0 to 278% in the two previously described
meta-analyses. Centres with most experience of oesophageal
THE LANCET Oncology Vol 4 August 2003

resection had mortality rates of below 5%. There is now

mounting evidence to support the notion that outcome is
directly related to volume of operations for complex
oncological procedures. Three studies using Medicare-linked
databases for reimbursed oesophagectomies have shown
significantly improved outcomes and lower mortality rates in
those centres designated as high-volume hospitals with regard
to oesophageal resection.29-31 It can therefore safely be
concluded that both transthoracic and transhiatal approaches
to oesophageal resection are safe in experienced hands, and
neither technique is superior.
Lymphadenectomy

Although in recent years postoperative mortality has declined

and rates of complete resection have improved, 5-year
survival after oesophagectomy procedures seldom exceeds
25%. Owing to extensive submucosal lymphatic drainage of
the oesophagus, nearly 80% of patients who undergo surgery
have positive lymph nodes. Nodal involvement is the single
most important prognostic factor in oesophageal cancer for
both locoregional and systemic recurrence after complete
resection.3235 FDG-PET36 and sentinel-lymph-node mapping37
have been used in efforts to improve clinical staging of
lymph-node involvement, and immunohistochemical
staining38 has been used to refine tumour detection.
Radical en bloc resections involving dissection of the
cervical, superior mediastinal, and celiac-axis lymph nodes
have been reported to reduce the rate of locoregional
recurrence and increase long-term survival in patients who
undergo oesophagectomy. Proponents of three-field lymphnode dissections argue that up to 30% of patients with mid or
distal oesophageal cancers have cervical lymph-node
metastases.3941 Despite the potential benefits of this approach
for staging oesophageal disease more accurately, whether it
results in improved local control and survival is less clear.
Several non-randomised series from single institutions have
been reported;1517, 4244 the authors suggest survival is
improved by use of extended lymphadenectomy, with
acceptable morbidity and low associated mortality (figure 2).
However, many of these studies are hindered by small sample
sizes, confounding the effects of additional non-surgical
treatment, and comparison to historical controls. Therefore,
any claims that radical lymph-node dissection alone is
reponsible for better outcome are speculative. One recent
single-institution study in the USA involved 80 consecutive
patients who underwent oesophagectomy with radical
lymph-node dissection. 5-year overall survival was 51%
better than that for historical controls, with no difference in
operative mortality and reasonable morbidity.45 30% of
patients in this study were upstaged as a result of extended
lymphadenectomy, as has been reported in the Japanese
experience.39,46,47 Only one prospective randomised trial has
been done to compare extended lymphadenectomy and
conventional procedures in 62 patients with resectable
squamous-cell cancer of the thoracic oesophagus.48 Despite
the fact that radical lymph-node dissection operations are
more lengthy and cause greater blood loss than conventional
methods, postoperative mortality is not significantly
different. In this small, single-institution series, patients who

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Surgery for oesophageal cancer

Table 2. Meta-analysis of trials comparing transthoracic (TTE) versus transhiatal (THE) oesophagectomy
N

Pulmonary complications (%) Anastamotic leak (%)

TTE

THE

RR (CI)

TTE

THE

RR (CI)

7527

187

127

147
(129-168)

72

136

5483

250

240

N/A

100

160

Postoperative mortality (%)

5-year survival (%)

TTE

Ref

THE

RR (CI)

TTE

THE

RR (CI)

053
92
(045-063)

57

160
230
(189-142)

217

106
27
(118-096)

N/A

63

N/A

240

N/A

95

260

28

RR (CI), relative risk (confidence interval); N/A, not applicable.

were assigned to undergo extended lymphadenectomy were

more likely to survive for 5 years that patients who
underwent conventional lymphadenectomy (662% vs 48%)
and were less likely to have disease recurrence (129% vs
241%). Neither difference was statistically significant
however. Furthermore, patients in this trial were
subsequently randomised to receive either chemoradiotherapy or chemotherapy alone after the operation,
which confuses the interpretation of this trials results.
Lymph-node dissection certainly provides more accurate
pathological staging of disease so stage migration may explain
some of the improved outcomes reported in many
series.23,49 This point underscores the importance of carefully
designed randomised controlled studies to find out if
therapeutic benefit can be attributed to extended
lymphadenectomy for oesophageal cancer. At present, such a
claim cannot be justified.
Minimally invasive oesophagectomy

Since improved outcomes have not consistently been shown

with radical procedures, further refinements in surgical
technique are unlikely to have a substantial impact on this
disease. Meanwhile, many investigators have begun to explore
more patient friendly procedures with the hope of
obtaining equivalent oncological outcome while reducing
morbidity and mortality. Non-surgical techniques such as
endoscopic mucosal resection are being applied for tumours
limited to the mucosa and may, with further study, prove to
be an effective alternative to oesophagectomy.50,51 Recently,
minimally invasive techniques of oesophageal resection have
been used. These procedures incorporate various
combinations of laparoscopy, thoracoscopy, and handassisted manoeuvers. Minimally invasive surgery offers many
theoretical advantages including minimising postoperative
pain, reducing length of stay in intensive-care units and
hospital, and decreasing overall cost. These factors improve
quality of care and outcome, enabling patients to regain a
normal lifestyle quickly.
Hand-assisted laparoscopic techniques can reliably mimic
open oesophagectomy and may be the ideal bridge between

open and totally laparoscopic or thoracoscopic procedures,

thereby reducing the need for surgeons to be specialist in
oesophageal procedures. 52 The hand-assisted approach
preserves the advantages of open procedures by offering
tactile sensation or feedback, and improved hand-eye coordination, while maintaining the benefits of a minimally
invasive procedure. The surgeons ability to feel the tumour
during the procedure helps ensure wide-field dissection and
adequate surgical margins. Proponents of minimally invasive
approaches argue that mediastinal exposure is improved and
lymph-node dissection is made easier by use of laparoscopic
or thoracoscopic techniques.
Initial studies have shown that minimally invasive
oesophagectomy can often be done relatively quickly, with
minimum blood loss, variable hospital stay, and no
substantial increase in operative morbidity or mortality over
conventional oesophagectomy techniques (table 2).5256
Lymph-node retrieval seems adequate and comparable to
that achieved during open oesophageal resection. However,
despite the fact that incisions are smaller, multiple body
compartments (abdomen, mediastinum, thorax, and neck)
are still disturbed, which is the major contributing factor to
the morbidity and mortality associated with oesophagectomy.
Indeed, this may negate the theoretical advantages of a
minimally invasive approach. In conclusion, no
scientifically generated data is currently available to support
significant advantages of the minimally invasive approach for
oesophagectomy over the open technique.
Numerous issues remain unresolved regarding the
clinical usefulness of minimally invasive oesophageal
resection. These include: the optimum approach;
applicability to general surgeons; cost-effectiveness; proof of
advantages over open techniques; and the role of minimally
invasive oesophagectomy in combined modality therapy.
When analysing a new technology, it is important to
distinguish between perceived and actual benefits and, in the
case of minimally invasive oesophagectomy, controlled
comparative studies will be essential for determining its true
value. At present this procedure remains an investigational
approach for cancer of the oesophagus.

Table 3. Results of minimally invasive oesophagectomy

N
77
18
9

Operative
time (min)

Blood loss Lymph nodes Hospital

(mL)
dissected
stay (days)

Complications (%)
Respiratory
Cardiac

Anastamotic leak

450
364
390

N/A
297
290

182
167
556

91
110
00

16
10.8
6

7
113
64

130
N/A
N/A

Mortality (%)

Ref

0
0
0

54
55
53

N/A, not applicable.

484

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Review

Surgery for oesophageal cancer

Table 4. Randomised controlled trials of preoperative

radiotherapy versus surgery alone for oesophageal
carcinoma
N

Histology

Preoperative
5-year overall survival (%)* Ref
radiotherapy
Surgery Radiotherapy
dose (Gy/time)
plus surgery

176

SCC/AC

20/2 wk

17

58

108

SCC

35/4 wk

21

59

206

N/A

40/4 wk

30

35

60

208

SCC

33/12 d

10

61

124

SCC

3945/812 d

115

95

62

*p=non-significant, 3-year overall survival. SCC, squamous-cell carcinoma; AC,

adenocarcinoma.

Surgery as part of combined modality therapy

The equivalence between incidence and mortality rates in the
USA for oesophageal cancer4 and the failure of surgery alone
to alter this pattern means that many oncologists favour
combined modality therapy. As a consequence, chemoradiotherapy, either with or without surgery, is the most
widely used treatment for patients with oesophageal cancer in
the USA.57 We have chosen to critically analyse the data from
available clinical trials to find out whether this trend in
treatment is justified or requires further study. The role of
resection as a component of combined modality treatment for
oesophageal cancer is now being scrutinised and its
superiority challenged.
Preoperative combined modality treatment

Phase III trials in which patients are randomised to either

preoperative radiotherapy or surgery alone have not shown a
survival benefit for combined therapy (table 3).58-62 This result
is not surprising however, since both radiotherapy and
surgery address local regional disease alone, yet the vast
majority of patients die from systemic recurrence. The results
of trials exploring the addition of chemotherapy to resection

are conflicting (table 4).6367 Two large multi-institutional

prospective randomised trials of preoperative chemotherapy
vs a surgical control have been reported.63,64 An intergroup
trial64 in the USA showed that survival was equivalent between
patients assigned induction chemotherapy (fluorouracil and
cisplatin) and resection, and those treated with surgery alone.
A similar trial by the UK Medical Research Council63 noted a
significant median and 3-year survival benefit for patients
randomised to preoperative fluorouracil with cisplatin
compared with surgery alone. Although a direct comparison
of several variables between the two trials suggests differences
in total dose of drug, percentage of intended chemotherapy
cycles that were delivered, and percentage of patients
randomised to combined modality who actually underwent
resection, we are still left with inexplicable disparate outcomes
in these two trials and, therefore, the worth of preoperative
chemotherapy remains questionable.
Recognition of the need for improved local regional
control, and also of the fact most patients succumb to distant
disease, has prompted many investigators to explore
preoperative chemoradiotherapy in an attempt to improve
outcome. There have been three prospective randomised
trials comparing induction chemoradiotherapy plus
oesophagectomy with oesophagectomy alone (table 5). At face
value, one of the studies68 showed a survival benefit with
combined modality therapy although the other two studies69,70
showed equivalent median and 3-year survival between the
groups. As with all clinical studies, each of these trials has its
supporters and detractors providing evidence to support their
own bias regarding the utility of combined modality therapy.
The positive study by Walsh and colleagues68 has been
criticised as a small, single-institution study with suboptimum
preoperative staging and an extremely poor outcome in the
surgical control group. Those who favour chemoradiotherapy
point out that in the negative EORTC trial, 69 which showed an
identical median survival between the two groups, there was a
significant decrease in number of deaths from oesophageal

Table 5. Randomised controlled trials of preoperative chemotherapy vs surgery alone for oesophageal carcinoma
N

Histology Regimen

Surgical mortality (%)

Surgery Chemotherapy p
and surgery

Median survival (months)

Surgery Chemotherapy p
and surgery

2-year survival (%)

Surgery Chemotherapy p
and surgery

Ref

802 SCC/AC

2 cycles of cisplatin plus

fluorouracil, then surgery

100

100

NS 133

168

NS

34

43

0004

63

440 SCC/AC

3 cycles of cisplatin plus

fluorouracil, then surgery
and 2 cycles of cisplatin
plus fluorouracil
postoperatively

60

60

NS 161

149

NS

37

35

NS

64

147 SCC

2 cycles of cisplatin plus

fluorouracil, then surgery

87

83

NS 138

162

NS

31

44

NS

65

75

SCC

3 cycles of cisplatin plus

fluorouracil then surgery

100

190

N/A 100

100

NS

N/A

N/A

N/A

66

39

SCC

2 cycles of cisplatin plus 00

bleomycin and vindesine,
then surgery, and
postoperative cisplatin
and vindesine for 6 months

120

NS 90

90

NS

N/A

N/A

N/A

67

SCC, squamous-cell carcinoma; AC, adenocarcinoma; NS, non-significant; N/A., not applicable.

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Table 6. Randomised controlled trials of neoadjuvant chemoradiation for oesophageal carcinoma

N

Histology Pathological
Surgical mortality (%)
complete response (%) Surgery
CMT

Median survival (months)

p
Surgery CMT

3-year survival (%)

Surgery
CMT

Ref
p

100

SCC/AC

280

40

21

NS

176

169

NS

160

300

NS

70

282

SCC

260

36

123

0012

186

186

NS

250

270

NS

69

113

AC

250

36

85

NS

110

160

001

60

320

001

68

SCC, squamous-cell carcinoma; AC, adenocarcinoma; CMT, combined modality therapy; NS, non-significant.

cancer in the preoperative chemoradiotherapy group.

However, skeptics counter that combined modality therapy
significantly increased postoperative mortality emphasising
the toxicity of this aggressive approach. The authors of a
negative trial from the University of Michigan70 reported
equivalent median survival for patients treated with
chemoradiotherapy and those who were assigned to surgery
alone, but stated that there is a statistically non-significant
trend toward improved survival with combined modality
treatment, and that the trial was underpowered to detect a
small, but potentially clinically meaningful, survival difference
between the groups. The only way of resolving these
conflicting results would be to design a large multiinstitutional phase III trial of chemoradiotherapy plus surgery
vs surgery alone. Such a trial was conceived of through the
intergroup mechanism in the USA in October, 1997, but was
prematurely closed after recruiting only 5% of the intended
number of patients.
The absence of benefit for preoperative chemoradiotherapy in the reported phase III trials means this approach
should be considered investigational. A consistent finding in
these three trials, as well as many phase II trials, is that 25% of
patients treated with induction chemoradiotherapy have a
complete pathological response with no residual tumour in
samples of resected tissue after oesophagectomy. One would
intuitively conclude that this group of patients does not
require surgery, since it is difficult to comprehend how
oesophagectomy offers any added benefit in this setting. By
contrast, a number of phase II trials, including our own,71
show long-term survival for patients with residual disease in
resected tissue after preoperative chemoradiotherapy, which
suggests oesophagectomy is necessary for this cohort and their
outcome would be compromised if residual tumour had been
left in situ. Ideally, surgery should be directed towards patients
who need oesophagectomy, so the risks of resection can be
avoided in patients who would derive little benefit. A similar
argument could be applied to chemoradiotherapy; however,
our ability to predict tumour biology before initiation of
treatment is, at best, limited.

Definitive chemoradiotherapy
The traditional role of surgery in the management of
oesophageal cancer has further been challenged by the results
of a phase III trial examining the usefulness of definitive
chemoradiotherapy. In RTOG 8501,72 patients were
randomised to receive chemoradiotherapy or radiotherapy
alone; neither treatment group underwent surgery. The
results imply that chemoradiotherapy is superior to
radiotherapy26% of patients in the combined modality
group were alive at 5 years compared with no patients who

486

received radiotherapy alone.18 The investigators appropriately

point out that 5-year survival for patients who were treated
with chemoradiotherapy was similar, or better, than that
reported for patients who have surgery. However, persistent
or recurrent local disease was present in about 40% of patients
treated with chemoradiotherapy, suggesting that if surgery
was also used, survival would be improved further. Obviously
the only way to resolve this issue would be to design a
randomised trial with surgery as the variable, ie, chemoradiotherapy plus surgery vs definitive chemoradiotherapy
alone. Although it was thought unlikely that a trial with this
design would ever be initiated, such a trial was reported in
abstract form at the 2002 Annual Meeting of the American
Society of Clinical Oncology in Orlando, Florida. 73 Of the
455 patients who began chemoradiotherapy, 259 patients who
had at least a partial response and no contraindication to
further chemoradiotherapy or surgery were randomised to
surgery or continuation of chemoradiotherapy. No difference
was noted for 2-year survival or median survival between the
two groups, although the 3-month mortality was significantly
higher (9% vs 1%) in patients who underwent surgery as a
component of their combined modality treatment. Although
no definitive conclusions can be drawn from this trial since, at
the present time, only the abstract is available for review, it
again challenges the role of surgery as a mandatory
therapeutic intervention for all patients with carcinoma of the
oesophagus.

Conclusions
The management of oesophageal cancer will undoubtedly
continue to evolve as improvements in technology, combined
with a greater understanding of genomics and biology of
tumours, better define effective therapeutic interventions and
allow introduction of novel treatments into strategies for
clinical management. The role of surgery is likely to change
over time, but will continue as a primary, or secondary,
treatment modality for a substantial number of patients with
oesophageal cancer. In patients with confined disease (stage I
and IIa), resection can be curative and the acceptable outcome
achieved by surgeons who are experienced at oesophagectomy
is unlikely to be challenged by other forms of therapy. Since
the vast majority of patients with locally advanced disease who
undergo chemoradiotherapy have residual disease in situ at
completion of treatment, common sense dictates that surgery
should be beneficial in achieving a long-term disease-free
state. Conversely, it is difficult to contemplate how surgery
would benefit patients who achieve a complete pathological
response with combined modality therapy, and therefore, they
should not be exposed to the risks associated with oesophageal
resection. Unfortunately, at present, we are unable to

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Surgery for oesophageal cancer

Search strategy and selection criteria

References for this review were identified by searches
of PubMed. Search criteria included the terms
esophageal neoplasm, esophagectomy, transhiatal,
transthoracic,
minimally
invasive
surgery,
laparoscopy or laparoscopic, thoracoscopy or
thoracoscopic,
radiotherapy,
chemotherapy,
chemoradiotherapy, and multimodality therapy.
Selected papers from the search results were retrieved
and only papers involving human studies, published in
English, were used for this review.

accurately pinpoint those patients who require some kind of

therapeutic intervention and those for who particular
treatments should be avoided. However, it is likely that in the
not too distant future, we will be able to establish a genetic
fingerprint for each individual patient that will dictate the
most efficacious therapeutic strategy in each setting. It is
important for us to separate fact from fiction when assessing
the effectiveness of therapeutic interventions and avoid the
pitfalls inherent in personal bias. For example, although
minimally invasive oesophagectomy has many theoretical
benefits, its worth has not been vigorously examined and,
therefore, the actual advantages over open oesophagectomy
are unclear and unproven. Likewise, the widespread use of
preoperative chemoradiotherapy on the basis of its presumed
therapeutic benefit should be weighed against the insufficient
evidence for an actual advantage over resection alone. The
challenge for us is not to accept the status quo and to
investigate new better options, but to do so in a scientifically
sound way that leaves little doubt to the accuracy of
therapeutic claims. In a disease where as many deaths occur as
new cases are reported each year, no therapeutic option,
including surgery, should be dogmatically accepted and
defended. We should all continue to search for more effective
applications of current treatments, and vigorously explore
innovative alternatives which must be validated through the
clinical-trial process.

11
12

13
14
15

16
17
18

19
20
21

22
23

24
25

26

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