Esophageal Cancer: Past, Present and Future

Podcast Transcript

Announcer:

Welcome to Cleveland Clinic Cardiac Consult, brought to you by the Sydell & Arnold Miller Family Heart, Vascular & Thoracic Institute at Cleveland Clinic.

Siva Raja, MD, PhD:

We have a lot of different types of esophagectomies. There's the left thoracoabdominal, transhiatal, Ivor Lewis, McKeown, and we're going to talk briefly about what those are, but to take this into context about just the fact that there's so many different ways to do this, and everybody at this time was trying to figure out which was the best way how to perfect this.

A McKeown esophagectomy is what they call the three-hole esophagectomy. You had an incision in the chest to be able to access the esophagus, and then you had a neck incision and an abdominal incision. It allowed you to dissect the esophagus, the lymph nodes in multiple different body cavities, specifically three different areas, hence the three-hole. The next one is an Ivor Lewis esophagectomy, which is probably the most commonly performed type of esophagectomy in the United States today, where you have an incision in the chest and an incision in the abdomen. An operation that is common and popularized at the Cleveland Clinic, which was the left thoracoabdominal incision. This incision was designed as a cancer operation. It allows people to get a variety of cancers out, allows you to get all the lymph nodes. This is a big operation, but it's an operation that facilitates curative intent.

Wanted to throw in a blast from the past. This is Dr. Rice who actually operated on Mr. Roselli a couple of times. He's already doing a left thoracoabdominal esophagectomy. And so we had perfected this operation and we take the cancer out, we take this esophagus, we make the stomach into a tube, and we pull it up. We can see pretty much everything through this incision. That makes this operation not only effective, but also an operation that is safe. If you can see it, it can keep you from getting into trouble. We can see that this is Dr. Rice making this, the gastric conduit, that can then replace the esophagus once that's removed.

So where do we go from here? We go, at this point, for an operation that used to be dangerous, something that is relatively safe. While we are curing disease, the issue for us was that we weren't necessarily making as much of an impact in patients who had locally advanced disease. So we had an operation that was good, but possibly not good enough, so we needed the next evolutionary step. That's why I have this car.

This is the 1996 Dodge Viper. It's not the exact year that it was in Mr. Roselli's garage, but this particular car has particular significance as it pertains to this. This car was actually introduced in 1992. It was a very good car, but a lot of people felt that it hadn't lived up to its potential. So even though they had a very good car, very performance-oriented car, the company decided they were going to completely revamp this. A lot of new technology went into this car to then make this car go from 0 to 60 in 4.6 seconds. The next barrier was to go to be under 5 seconds, and this was one of the cars that was able to make it at the time.

For esophageal cancer treatment, it was the addition of additional therapy such as chemotherapy. This is the first paper that looked at chemotherapy in addition to surgery for the treatment of esophageal adenocarcinoma. It was published by Dr. Walsh in 1997 in the New England Journal of Medicine, and it was a paradigm shift. There were some criticisms of this paper in the sense that they thought that the surgical arm survival was not as good. As a result, it took several additional studies to be able to prove that this effect was indeed true. This leads us to the definitive study that was performed between 2004 and 2008, which was subsequently published in 2012 that talked about preoperative chemotherapy for esophageal cancer, and finally, we were able to show that, the surgery that we had already perfected, we were able to get better than that. So at this point now we're talking about half the people surviving their locally advanced cancer.

With this new information, we were ready to then apply everything that we knew to the treatment of esophageal cancer in the form of multimodality therapy. So we are ready to go cruising at this point and comes in our next participant in this discussion. This is the 2009 Corvette Grant Sport. This put all of the new technology we knew at the time we had onboard computers, we had Bluetooth, it went from 0 to 60, 4.1 seconds. We were, at this point, ready to get fancy with the treatment of esophageal cancer. And this was really the first step in the standardization of the treatment. Since the study was published in 2012, almost every patient in the United States getting treated for esophageal cancer was going to get chemoradiotherapy followed by surgery if they had locally advanced disease.

So at this point, we take an operation that was pretty big and we start to use minimally invasive techniques in it. The minimally invasive esophagectomy was introduced in the last couple of decades, and this was one of the first papers that was published in 2000 that looked at minimally invasive esophagectomy. It was about 77 patients and said it was feasible. So then we told ourselves that if we can do a large operation like a thoracoabdominal operation with an incision that left you with this, it has to be a good thing. And so we decided that this was going to change everything. And so if you can do 77 patients very quickly we were at about 1,000 patients getting this kind of operation. And you can see we now are at a mortality rate about 1.6%. So we went from 44% to now 1.6% in a very short period of time.

Even taking this operation as it pertains to today, we can see that this has been the trend of how people have been using esophagectomies. In 2007, it was predominantly open operation. By 2014, around the time this paper was published, about half the people were getting minimally invasive esophagectomies, the other half were getting open operations. And we can sort of see that the pendulum has sort of swung a little bit more. We still have about half the people getting it, and then there's called a hybrid esophagectomy where people take parts of minimally invasive techniques and apply it, and then of course, a certain percentage still have open operations.

Because we have something fancier, the question is, is it still better? Now, obviously, if it's a smaller incision to accomplish the same thing intrinsically, that alone makes it worthwhile to do the operation. But the question is, was it dramatically better? This was actually a paper looked at the data that was looked at by Dr. Raymond, who's actually in the audience today, around the same time, and what they found was about a third of the patients at that time of the study in the general thoracic database were getting minimally invasive surgery and about two-thirds were getting open operations. For the most part, most of the esophagectomies, if it went well, they end up doing about the same. So it turns out that it's less so about how you get there. It's about what you do when you get there.

That being said, even if it looks like it's not dramatically different in terms of other metrics, like how long do they stay in the hospital, how often they're cured from their cancer, the fact is it's still a less traumatic operation on a human being, and therefore it has to be better. So we're not actually trying to get the genie back in the bottle, but we're trying to figure out what it is that someone should do. So what is the optimal approach for esophagectomy?

We think that the biology should dictate what operation one gets, which is that based on the location of the cancer, which is if the cancer were in the neck or in the lower part of the chest, they would get a McKeown, which is the operation that allows you to operate in the neck as well. If the cancer were lower down, you could do either operation as long as you're able to do it well. Now, if you had mostly stomach cancer with some esophageal involvement, then the thoracoabdominal operation is now being used. If you are a very large patient for morbid obesity, the thoracoabdominal operation is a very good operation.

But if all things are equal, it is that you want to do your favorite approach. Now, why is that important? Well, if you like an approach, you're probably doing it because you're good at it, and in a high complexity, low-volume operation, especially in the United States, it's very important that you do the operation well, more so than how you do the operation.

Announcer:

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