Cancer and the oesophageal surgeon

Over 95% of all oesophageal cancers are either adeno- or squamous cell carcinomas. With increasing growth they cause dysphagia, weight loss and bleeding. Diagnosis is made with endoscopy and biopsy, and staging is completed by endoscopic ultrasound, abdomino-thoracic CT scan and PET. The UICC TNM classification is used to stage oesophageal tumours, and in gastro-oesophageal junction tumours the anatomical classification described by Siewert is commonly used when planning surgical resection. Patients with locally resectable tumours and no distant metastases are classified as curative candidates. For these patients the gold standard for treatment is surgery with or without neoadjuvant radio-chemotherapy. Tumours stage T2 or higher and/or N1 are usually considered for neoadjuvant treatment. Additional to the oncological staging, a risk analysis for each individual patient should be performed as oesophagectomy is associated with significant risks of morbidity and mortality. Co-morbidity, age and the number of surgical procedures performed by the treating institution are important predictors of outcome. Surgery is performed either with open, or minimal invasive techniques. The stomach is most commonly used conduit to replace the oesophagus, with a segment of large bowel an alternative in some individuals. Post-operative morbidity includes anastomotic leak, empyaema, chylothorax, and most importantly respiratory complications. After multimodal treatment, survival is between 20% and 40% at five years. In patients with locally advanced tumours, metastases, or who are unfit for surgery, definitive radio-chemotherapy is the treatment of choice. Standard treatment regimens include radiotherapy (50 to 60 Gy) and chemotherapy with 5-FU and Cisplatin. If stenosis or obstruction is present, adjuvant interventions such as stent placement, dilatation and argon plasma ablation may be used.