MD Anderson surgeons pioneer organ-sparing therapy for esophageal cancer

Until recently, patients with esophageal cancer were treated with esophagectomy, or removal of the affected part of the esophagus and surrounding lymph nodes, followed by reconstruction. Barrett esophagus with high-grade dysplasia, which carries a substantial risk of progressing to cancer, was treated the same way. However, esophagectomy leads to significant lifestyle changes, including diet limitations and an inability to sleep horizontally; and the operation itself can be dangerous for some older patients. Now, an increasing number of patients with early-stage esophageal cancer or dysplastic Barrett esophagus can be effectively treated with esophagus-sparing surgery and/or ablation.

But doctors with the esophageal surgery program at MD Anderson are incorporating new modalities in the diagnosis, treatment and prevention of esophageal cancer. Oncolog’s Sarah Bronson wrote about how these physicians are focusing on first-line strategies in managing esophageal cancer and continuing to seek better up-front choices for patients with early disease.

First steps

To determine the appropriate course of treatment, patients with suspected esophageal cancer or dysplastic Barrett esophagus are given a thorough staging workup. This workup usually includes endoscopic ultrasonography to identify tumor tissue, determine how deep the tumor extends into the esophageal wall, and determine whether the disease involves the lymph nodes.

Endoscopic mucosal resection

Patients with esophageal tumors that appear superficial on workup can undergo endoscopic mucosal resection (EMR), a definitive resection in which the esophagus is accessed via the mouth and pharynx.

EMR avoids a full-thickness injury to the esophagus and is easier for patients to withstand than open surgery. Whereas open esophagectomy is a 6-hour operation that requires a significant amount of physiological reserve and several days of postoperative recovery in the hospital, EMR is an outpatient procedure that requires patients to tolerate only 45 minutes of anesthesia and is associated with a better quality of life.

Pathological interpretation of the resected tissue determines if EMR needs to be followed by esophagectomy. 

Based on their experience with EMR, Wayne Hofstetter, M.D., professor of Thoracic and Cardiovascular Surgery and director of the esophageal surgery program, and his colleagues rewrote the Society of Thoracic Surgeons’ guidelines for treating early-stage esophageal cancer in 2013, and the former gold standard of esophagectomy has been replaced by EMR combined with ablation. The National Comprehensive Cancer Network guidelines also now designate EMR as a standard therapy for early-stage disease.

Ablation

Endoscopic ablation is used as an adjuvant to EMR for patients with superficial tumors or as the sole treatment for patients with dysplastic Barrett esophagus whose disease is not nodular. One of two ablation modalities may be used. The first, radiofrequency ablation, delivers heat energy to the lining of the esophagus, leading to tissue destruction. Radiofrequency ablation can be administered by a balloon catheter, by a metal plate mounted at the tip of an endoscope, or by other devices. The second modality, cryoablation, uses cold gases, such as liquid nitrogen or carbon dioxide, dispensed from the end of a probe to freeze and kill abnormal cells.

The ablation modality chosen for a specific patient depends on the anatomy and the characteristics of the Barrett segment. “If we are dealing with a flat area of Barrett esophagus, we prefer radiofrequency ablation,” said Marta Davila, M.D., a professor in the Department of Gastroenterology, Hepatology, and Nutrition. “If there is mild nodularity to the area and cancer has been excluded by previous EMR, we may prefer cryoablation, which can go slightly deeper than the mucosa and into the submucosa.” Cryoablation is also used in patients for whom radiofrequency ablation failed.

Next steps

In the future, esophagus-preserving therapy could be extended to more types of patients with esophageal cancer. For example, patients with regional extension of cancer to the lymph nodes, which is currently treated with esophagectomy, could receive local therapy with EMR plus ablation within the esophagus and surgery or chemoradiation for the affected nodes.

Also on the horizon are systemic therapies in new combinations.

“We’re trying to find ways of pushing patients’ response to medical therapy or chemoradiation to the point where they don’t need surgery,” Hofstetter said.