Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 65, Num. 4, 2003, pp. 320-325

Indian Journal of Surgery, Vol. 65, No. 4, July-Aug, 2003, pp. 320-325

Review Article

Cancers of the oesophagus and gastrointestinal tract - changing concepts

Praful B. Desai

Department of Oncosurgery, Bombay Hospital Institute of Medical Sciences, Marine Lines, Mumbai 400020.
Address for correspondence Dr. Praful B. Desai, 307, Samudra Mahal, Dr. A. B. Road, Worli, Mumbai 400 036. E-mail: praful@bol.net.in

Paper Received: January 2003. Paper Accepted: January 2003. Source of Support: Ni

How to cite this article: Desai PB. Cancers of the oesophagus and gastrointestinal tract - changing concepts. Indian J Surg 2003;65:320-4.

Code Number: is03065

Introduction

Cancers of the gastrointestinal tract form a major component of the workload of a busy general surgeon or a surgical oncologist. Despite advances in chemotherapy and radiotherapy, surgery still remains the sina qua non in the management of GI tract cancers. Changing trends and differing opinions, based on current surgical research dominate the management of lymph node dissections.¹ Investigative work on sentinel node biopsy (SNLB) in oesophagus, stomach and colon cancers has been reported as an analogy to breast cancer.² Dissection and removal of normal non-infiltrated nodes in the GI tract do not produce the kind of morbidity as seen in breast cancers and hence the study of SNLB in GI tract cancers can, at best, be seen as an academic exercise.

Appropriate removal of draining lymph nodes not only allows precise staging but it is of great help in planning adjuvant therapy and determining prognosis in a given patient. None of the advances, either in molecular biology or chemotherapy have changed the standard surgical approach to GI cancers. If at all there is a shift, it is related to the appropriate interpolation of multidisciplinary approach, and the extent of surgery at various sites in the GI tract.

Cancer of the oesophagus

Based on current evidence, it would be correct to state that non-metastatic loco-regional squamous cancer of the oesophagus is currently best treated by a surgical excision. It is also a fact that overall results and survivals for resectional surgery remain poor as only 10 to 15% 5-yr survivals continue to be reported by most authors, though the range varies from 10 to 45%³ depending upon the stage of disease at which resection is performed.

Major debate continues regarding the surgical approach and the extent of lymph node dissection (2 field or 3 field). Without going into the merits and demerits of the extent of the dissection, it is well documented that removal of infiltrated lymph nodes in oesophageal cancer has produced long-term controls and a few cures.⁴ The oesophagus has a very rich submucosal lymphatic plexus and for this reason squamous cancer of the oesophagus has a special predilection for lymph node invasion. Adequate nodal dissection therefore must form an important part in oesophagectomy for squamous cancers. Technical expertise in surgery for cancer oesophagus is a factor of vital importance as it is a fact that an occasional oesophageal surgeon (less than 10 resections/year) is a greater risk factor to the patient than the disease itself.^` Total or subtotal oesophagectomy have their indications and intrathoracic (left or right) anastomosis have stood the test of time.

No conservation therefore is permissible while operating on oesophageal cancer; the nodes in the proximity of the lesion must be dissected adequately, e.g. coeliac, left gastric, lesser curvature, para oesophageal and the subcrainal nodes in lesions of the cardio-oesophageal junction and lower oesophagus. Dissection of nodes should be extended up to the apex of the chest when the lesion is in the mid-segment of the oesophagus.

Cervical node dissection is a subject of debate and dissection of this third field, in most hands, has increased immediate postoperative and delayed morbidity;⁶ in experienced hands - particularly in the hands of the Japanese surgeons - the morbidity and mortality are acceptable. However, suffice it to say that three-field dissections have not come for general acceptance and should not be undertaken except under the ambit of institutional clinical research where good surgical expertise is available.

Surgical excision of oesophageal cancer with adequate regional lymph node dissections has stood the test of time and should be persisted with. Addition of neo-adjuvant chemotherapy and radiotherapy will help to reduce the tumour and nodal burden but cannot be depended upon to cure, except for an occasional anecdotal cure or prolonged control. After the rigours of major oesophageal surgery, chemotherapy and radiotherapy in an adjuvant setting are poorly tolerated and there are no adequate trials or data which prove any significant survival difference⁷ and adjuvant therapy is therefore best avoided.

The transhiatal approach is now well accepted by people who have large experience; lymph node clearances will be limited by this approach though equivalent results are reported as transthoracic approach.⁸ Cervical or intrathoracic anastomosis have their proponents. With experience, anastomotic dehiscence should be in the range of 5 to 8 % which is acceptable. Most of these patients with dehiscence can be and must be salvaged if a vigilant early diagnosis is made and quick attempts to rid sepsis are undertaken. Cervical anastomosis leaks more frequently, (15 to 20%) and heals by fibrosis; functional results after cervical leakage and consequent fibrosis are poor and repeated dilatations result in a poor quality of life. Based on one's own experience, the transhiatal or transthoracic approaches are equally acceptable. The author is a proponent of the latter approach. The selection criteria for the transhiatal approach should be carefully evaluated. Patients with disease beyond the oesophagus and those with likely presence of significant nodal burden are poor candidates for the transhiatal approach. Hand-sewn or stapled anastomosis depends on one's own choice. Leakage, stenosis and fibrosis are almost similar with either method though stenosis is more often noted in stapled anastomosis. The stomach remains the best conduit to restore continuity.

No significant changes have occurred in the surgery of cancer of the oesophagus for nearly 5 decades and the principles have remained the same.

Gastric cancer

In an era of shifting paradigms the only point which needs clarification in the surgery for gastric cancer is the extended D2 type of lymph node dissection as initiated and advocated by the Japanese group.⁹ Much published data and good randomized trials done by Dutch and South African groups clearly indicate that extensive D2 dissection of lymph nodes (para-aortic, pancreatico-duodenal, hepatic, retro-pancreatic, etc) not only does NOT improve survivals but is compatible with increased morbidity and mortality.¹⁰

The age-old principle of wide (5 cm tumour-free margin) excision of the primary lesion and adequate lymph node dissections is still the epitome of surgery for gastric cancer. The amount of stomach excision will depend upon the extent and location of the primary lesion. An infiltrating large lesion on the lesser curvature will require a total gastrectomy as also the lesions of the midbody and proximal stomach. Distal antral and pyloric lesions can be adequately treated by radical distal gastrectomy; preoperative endoscopy is often vital in determining the extent of gastric resection. Recurrences in the proximal gastric stump are frequent if the resection is not wide enough when so required; nodal recurrences are a major source of poor results as infiltrated nodal disease and tissues left behind are quick to recur, can interfere with function and quality of life (QOL) and are a major source for liver metastasis. R2 resection (macroscopic disease left behind) requires adjuvant postoperative chemotherapy and radiotherapy, the benefits of which remain questionable as no survival benefits have been demonstrated and the QOL is poor with adjuvant therapy.

Currently, conventional surgical principles hold sway, nothing has significantly changed and no paradigm shifts have occurred in the surgery for gastric cancer. We need to diagnose gastric cancer early if a satisfactory result has to be achieved.

In the age of exploding hyper information, it may be good medicine to administer adjuvant 5-Fluorouracil (5-FU) based chemotherapy if nodal invasion is significant as it may be difficult to defend an act of omission if a recurrence occurs (as is likely in most cases). As mentioned earlier some marginal benefits have been documented for adjuvant chemotherapy in patients with nodal spread. Nothing can substitute good appropriate cancer surgery of following surgical principles of yore, of wide excision of the primary lesion and adequate removal of lymph node bearing areas including the greater omentum (D1 dissection).

Cancer of the colon

Some paradigm shifts have occurred in colo-rectal cancers.¹¹ Investigations of sentinal node status in colo-rectal cancers are only of academic and clinical research interest since removal of normal lymph drainage areas produce no deleterious consequences as in breast cancer or melanoma. Surgical principles of right transverse and left hemicolectomy have remained steadfast.

5-FU based adjuvant chemotherapy in the presence of Duke's `C' disease (serosal involvement and nodal infiltration) is standard care and must be offered.¹² Though 5-FU is the gold standard with leucovorin, newer cytotoxics like irinotecan, oxalaplatin and oral camptosar (5-FU) are being increasingly used. No definite statements can be made and it will take quite some time before the gold standard of 5-FU / leucovorin can be replaced.

Greater understanding of the genetics of colon cancer is a major step forward. The polyp-adenoma­-carcinoma sequence has been reinforced and careful regular surveillance of HNPCC and HPCC is an absolute necessity. Genetic mutations in the stool samples, haemoccult fecal tests and periodic appropriate colonoscopies are investigative approaches to get ahead of colonic cancers. Tumour markers are useful in monitoring the course of a cancer though of no value for early diagnosis. Surgeons routinely managing colonic cancers are aware of the benefits of major excision (of adjoining infiltrated structures) along with the primary lesion when indicated.

Examples include resecting parts of muscles of the anterior or posterior abdominal wall, parietal peritoneum, small bowel, or duodenum and pancreas (colo-whipple). Surgical expertise should not be wanting if such an exigency arises. Adjuvant chemotherapy or radiotherapy may have to be considered after such supra-major excisions. Advent of newer chemotherapy has NOT changed this surgical principle of such major excisions when indicated.

Rectal cancers

While the gold standard abdominal perineal resection with a permanent colostomy continues to be performed for rectal cancers, its overall frequency is probably less. Sphincter-saving procedures for low rectal cancers are more frequently undertaken and the use of stapler probably facilitates a low anastomosis. Margins of 2 to 3 cm are now acceptable at the distal cut end so that more sphincter-saving procedures can be undertaken.

Neo-adjuvant chemotherapy and radiotherapy are practised in locally advanced rectal cancer to shrink the tumour mass and enable one to perform a sphincter-saving procedure. It is not yet proven whether a large tumour in the rectum (where abdominoperineal (AP) resection is indicated) can be safely tackled with a sphincter-saving procedure after neo-adjuvant chemotherapy or radiotherapy helps in reducing the tumour bulk.

In our enthusiasm to perform more sphincter-saving procedures we may be risking more local recurrences, more anastomotic leakage and stenosis, the lower we go for a colo-anal anastomosis. A good clinical dictum is that when the whole lesion can be easily felt with the examining finger, it may not be a very suitable lesion for a sphincter-saving procedure.

Mesorectal excision is a recent term. In essence it only emphasizes the wide removal of para-rectal tissues and lymph node bearing areas around the rectum. The para-rectal low pelvic tissues can be inadvertently left behind and will act as a major source of local, pelvic and perineal recurrences which are not uncommon after AP resections. It is simply good surgery to remove all para-rectal tissues from the deep end of the pelvis up to the pelvic walls. Local recurrences may show a downward trend if this important pelvic procedure is appropriately carried out after going through a learning curve.

Postoperative radiotherapy and chemotherapy are currently used as an adjunctive approach after surgery for locally advanced rectal cancers. It would probably be more correct to use neo-adjuvant chemotherapy or radiotherapy for a locally advanced cancer and do a good AP resection with wide mesorectal margins to reduce local recurrences in the perineum.

At all times preservation of the nervi erigentes which can usually be demonstrated should be the goal as preservation of potency is an important QOL issue.

Cancer of the anal canal

Squamous cell cancer of the anal canal is no longer a surgical disease and the standard of care is chemotherapy and radiotherapy. A very high percentage, in the excess of 70%, responds dramatically and only in the rare situation of a very advanced, locally infiltrating squamous cell carcinoma of the anal canal would AP resection be warranted. There is no justification whatsoever for an AP resection in squamous cell carcinoma of the anal canal.

The standard drugs used are Mitomycin-C and 5 Fu. Within 3 cycles nearly 70% of anal canal lesions regress dramatically. Residual tumours could be treated by adding radiation therapy. In about 15 to 20% cases where responses are poor, AP resection will have to be resorted to. Also, in those patients who present with large infiltrating tumours, neo-adjuvant therapy will have to be followed by AP resection.

Future vistas

The evolution of new technology at a hectic pace continues to confound the surgeon as we peruse literature. The establishment of laparoscopic cholecystectomy as a gold standard has unleashed a plethora of contributions regarding the use of laparoscopy (minimally invasive therapy) in surgery for malignancy of the gastrointestinal tract.

There is no doubt that the technological feasibility of executing major oncological procedures in the gastrointestinal tract has been established. Whether this will come for a routine adoption (even amongst laparoscopic surgeons) is highly debatable at the present time.

We are still trying to answer the question as to how these techniques will affect one's oncological goals, because there are insufficient data on long-term survivors and recurrence of disease.

Recent results of various studies on laparoscopic versus open gastrointestinal surgery (for cancer) led the American Society of colorectal surgeons to issue a policy statement (1994) that laparoscopic colectomies should NOT be performed outside a prospective randomized clinical trial.

An ongoing study, the "COLOR" study¹³ group reports that accrual of nearly 1200 patients undergoing laparoscopic versus open colectomies will be completed by the end of 2002 and they hope to present the results of the study in the near future. Lacy¹⁴ and associates report on a prospectively randomized study of 219 patients, stating that laparoscopic colonic resection was associated with a shorter ileus and hospital stay, lower morbidity and a higher probability of cancer-free survival. This is probably due to decreased surgical stress and less immunosuppression with the laparoscopic techniques.

In contrast, Jacobi et al¹⁵ reviewed the implications of laparoscopy and found several alterations in the peritoneal environment that might influence tumour growth. Winslow¹⁶ and co-workers found higher complications at the extraction sites for laparoscopic colonic resections.

Reports from the National Cancer Institute sponsored studies suggest that the current consensus indicates that laparoscopic resections for gastrointestinal cancers be confined to clinical trials at this time.¹⁸

As mentioned earlier the current research potential of sentinal node mapping in GI tract cancers is of questionable clinical relevance and it has not been widely accepted or practised.

The advent of effective neo-adjuvant therapy (chemotherapy) and endoscopic ultrasonography for staging has impacted on the surgical approach to low rectal cancers as many investigators attempt low anterior resections, colo-anal anastomosis or even transanal excision for rectal cancer.

A recent report from Minnesota,¹⁸ after such a conservative approach, demonstrated a local recurrence of 28% compared with 6% for the conventional oncological procedure. Such issues raise concern and emphasize that we cannot and should not jettison the basic surgical principles of oncological surgery in favour of using high technology which will ultimately prove detrimental to the patient's interests. We must remember that at this point in time AP resection with total excision of mesorectum and sphincter preservation (anterior resection) when indicated remains the standard of care in the treatment of invasive rectal cancer and a conservative procedure like transanal excision should be considered extremely carefully despite the availability of modern diagnostic CT scan / endosonography (EUS) and therapeutic technology (staplers).

References

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