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PRODUCED BY AND FOR MEMBERS OF THE DEPARTMENT OF SURGERY June 2014 | Archived Issues

The Multispecialty Approach to Esophageal Cancer

By Harmik J. Soukiasian, MD
Associate Director, Thoracic Surgery

Esophageal cancer usually begins in the cells in the inner layer (the mucosa) of the esophagus and grows outward (through the submucosa and the muscle layer). There are two types of cells that line the inside of the esophagus. As such, there are two main types of esophageal cancers: squamous cell carcinoma and adenocarcinoma.

Squamous cell carcinoma may develop anywhere that squamous cells line the esophagus; it develops mainly in the upper and mid-esophagus. However, adenocarcinoma is usually restricted to the lower third of the esophagus, where it joins the stomach (gastro-esophageal junction).

The incidence of esophageal cancer has risen in recent decades. The rate of adenocarcinoma also has risen, and it has become the most prominent type of esophageal cancer in the U.S. In fact, esophageal cancer is one of the fastest-growing cancer diagnoses in the United States, having increased 600 percent in the past 35 years.

Risk factors for squamous cell carcinoma of the esophagus have been readily identified. They include smoking, alcohol, drinking hot or scalding liquids, and diet.

The risk factors associated with esophageal adenocarcinoma are not as clear. Studies suggest that there seems to be a very strong correlation with gastroesophageal reflux disease as a risk factor for esophageal adenocarcinoma. The frequency, severity and duration of reflux symptoms were positively correlated with increased risk of esophageal adenocarcinoma. The presence of Barrett's esophagus (precancerous changes in the cells of the lower esophagus) is associated with an increased risk of developing adenocarcinoma of the esophagus. Interestingly, chronic reflux is considered the main cause of Barrett's metaplasia.

To help our patients with the diagnosis of esophageal cancer, our goal and primary objective at the Cedars-Sinai Esophageal Program has been to formulate a comprehensive, compassionate and evidence-based approach to the treatment of this disease. Studies have shown that the outcomes and survival of esophageal cancer surgery patients is better when performed in institutions that perform 20 or more esophagectomies per year, such as at Cedars-Sinai. In fact, with our continued dedication to improving our outcomes, our esophageal cancer volume continues to grow and is now among the highest in the region.

The Esophageal Program strives to deliver leading-edge treatment to our patients. The treatment of esophageal cancer is best managed using a team approach, including gastroenterology, medical oncology, radiation oncology and surgery, an approach we refer to as the multispecialty esophageal cancer approach.

In regards to the surgical approach, there continues to be a natural progression towards smaller incisions and minimally invasive approaches in all fields of surgery. Open cholecystecomy has been replaced by laparoscopic cholecystectomy, open prostatectomy is being replaced with robotic assisted prostatectomy, open gastric bypass has been replaced by laparoscopic Roux-en-Y gastric bypass, open lung resections are trending toward minimally invasive video-assisted thoracic surgery techniques, and now open esophagectomy is seeing the early phases of minimally invasive approaches.

Only a few medical centers worldwide perform minimally invasive esophagectomy (MIE) on a routine basis, due mostly to the fact that MIE is a complex and technically challenging procedure. Studies have shown that MIE has favorable results, with shorter operating times, less blood loss and less time spent in intensive care units and in the hospital. More than 90 percent of all esophagectomies at Cedars-Sinai are performed via a minimally invasive approach, with excellent results.

As a comprehensive esophageal program, we need to ensure that clinical trials are available to our patients. We are enrolling patients at Cedars-Sinai for a clinical trial looking at the genetic makeup of the tumor prior to surgery: RTOG-1010 — A Phase III Trial Evaluating the Addition of Trastuzumab to Trimodality Treatment of Her2-Overexpressing Esophageal Adenocarcinoma (IRB no. 32466).

The Cedars-Sinai multispecialty esophageal cancer approach offers patients the opportunity to be seen and evaluated by the most comprehensive group of physicians, pain management experts and social services at a single institution in Southern California. We are committed to offering our patients the best treatment options available, to advancing the field through thoughtful clinical research, and to establishing a relationship with our patients that will enhance and optimize their care.