Carcinoma of the Oesophagus - Treatment by Location

General Principles Before Location-Specific Treatment

1. Tumour location (cervical / upper third, middle third, lower third / OGJ)
2. Tumour stage (T and N stage)
3. Histology (squamous cell carcinoma vs. adenocarcinoma)
4. Patient fitness (cardiorespiratory reserve, nutritional status)

Upper One Third (Cervical Oesophagus)

"Definitive chemoradiotherapy has become the preferred alternative treatment to preserve the larynx. Surgery is therefore mostly reserved for salvage, when there is an incomplete response or for recurrent disease."

• Bailey & Love's, 28th Ed

• Pharyngo-laryngo-oesophagectomy (PLO): removes the pharynx, larynx and oesophagus en bloc; a gastric pull-up is used to anastomose with the neo-pharynx.
• If cervical oesophageal involvement is limited: pharyngo-laryngo-cervical oesophagectomy (without total oesophageal resection). The resultant gap is bridged using:
  • A free jejunal graft, or
  • Various musculocutaneous flaps
• Intraepithelial carcinomas of the upper oesophagus can also be considered for pharyngolaryngo-oesophagectomy with radical neck dissection and a transhiatal oesophageal resection (Scott-Brown's).

Middle One Third (Mid-thoracic Oesophagus)

• McKeown (Three-stage / Three-phase) Oesophagectomy - the preferred operation for mid-thoracic cancers:
  1. Right posterolateral thoracotomy to mobilise the thoracic oesophagus and perform mediastinal lymphadenectomy
  2. Abdominal incision (laparotomy) for gastric mobilisation
  3. Neck incision for cervical anastomosis (oesophagogastrostomy in the neck)
• A supra-azygous dissection is performed for middle-third cancers or when staging shows nodes above this level.
• A routine three-phase procedure with neck dissection "is required when the oesophageal lesion is in the upper third or upper part of the middle third of the oesophagus."

• Lewis-Tanner (Ivor Lewis) procedure - a two-phase oesophagectomy: laparotomy for gastric mobilisation, followed by right posterolateral thoracotomy with intrathoracic anastomosis. This approach can be used for middle-third tumours though the anastomosis is in the chest rather than the neck.

Lower One Third (Lower Thoracic Oesophagus and Oesophagogastric Junction)

"Two-stage oesophagectomy with a radical lymphadenectomy has been shown to improve outcomes for lower-third adenocarcinoma."

• Scott-Brown's

• Lewis-Tanner (Ivor Lewis) Procedure - the standard operation for lower-third cancers:
  1. Laparotomy - gastric mobilisation, tubularisation, preservation of right gastroepiploic and right gastric vessels, pyloroplasty/pyloromyotomy, feeding jejunostomy insertion
  2. Right posterolateral thoracotomy (4th or 5th intercostal space) - thoracic oesophageal mobilisation, en-bloc resection with thoracic duct and mediastinal lymph nodes, intrathoracic anastomosis
• Left Thoracoabdominal incision (Sweet oesophagectomy): A single left posterolateral incision through the 5th-6th intercostal space accessing both the left chest and abdomen; diaphragm opened for gastroplasty. Note: this does not afford optimal access for formal abdominal or complete mediastinal lymphadenectomy.
• Transhiatal oesophagectomy: Cervical + abdominal approach; oesophagus mobilised bluntly without thoracotomy; gastric conduit delivered to neck for cervical anastomosis. Suitable for lower-third tumours, though it does not allow adequate mediastinal nodal dissection.

• Above approaches apply with the addition of extended total radical gastrectomy (whole stomach + lower oesophagus resected, intestinal continuity via Roux-en-Y jejunal loop)
• In selected patients with early disease: proximal gastrectomy

Minimally Invasive Approaches (All Locations)

• VATS (video-assisted thoracoscopy) + laparoscopy, or
• Robotic techniques Both thoracic and abdominal phases can be minimally invasive, or one phase can be open (hybrid). The anastomosis can be fashioned in the chest or the neck.

Staging-Based Treatment Summary

Special Note on Histology and Radiotherapy

• Squamous cell carcinoma (predominates in upper and middle third): More radiosensitive; definitive chemoradiotherapy is a recognised curative alternative, especially in the upper third and for patients unfit for surgery. Salvage oesophagectomy remains an option after chemoradiotherapy failure.
• Adenocarcinoma (predominates in lower third and OGJ): Less responsive to radiotherapy alone; perioperative chemotherapy (FLOT/MAGIC protocol) or neoadjuvant chemoradiotherapy (CROSS protocol) before surgery is the standard.

Palliation

• Self-expanding metallic stents (SEMS): First-line for dysphagia palliation. Note: stents carry risk of airway compression/tracheal erosion when placed in the mid/upper oesophagus.
• Chemotherapy, radiotherapy, brachytherapy
• Laser, dilatation, photodynamic therapy
• Immunotherapy has promise in selected patients.

Carcinoma of Oesophagus - Treatment by Location

(Bailey & Love's Surgery - Exam Format)

QUICK MEMORY AID

UPPER ONE THIRD (Cervical Oesophagus)

Treatment of Choice: DEFINITIVE CHEMORADIOTHERAPY

• Preferred to preserve the larynx
• Surgery is reserved for salvage only (incomplete response / recurrence)

When Surgery is Done:

• Removes pharynx + larynx + oesophagus en bloc
• Reconstruction: Gastric pull-up anastomosed to neo-pharynx
• If limited cervical involvement: Pharyngo-Laryngo-Cervical Oesophagectomy
  • Gap bridged by free jejunal graft OR musculocutaneous flap
  • • Radical neck dissection

Exam Point: Surgery for upper-third = total laryngectomy is unavoidable, hence chemoradiotherapy is preferred first-line.

MIDDLE ONE THIRD (Mid-thoracic Oesophagus)

Treatment of Choice: McKEOWN (THREE-STAGE) OESOPHAGECTOMY

Three Stages:

1. Right posterolateral thoracotomy - mobilise oesophagus + mediastinal lymphadenectomy (supra-azygous dissection included)
2. Laparotomy - gastric mobilisation + tubularisation
3. Neck incision - cervical oesophagogastric anastomosis

Why McKeown for middle third?

• Cervical anastomosis is safer (leak causes less morbidity than intrathoracic leak)
• Supra-azygous lymph node dissection accessible
• Adequate proximal resection margin

Exam Point: McKeown = 3 incisions (chest + abdomen + neck). Neck dissection is routine for upper-middle third tumours.

LOWER ONE THIRD (Lower Thoracic + OGJ)

Treatment of Choice: IVOR LEWIS (TWO-STAGE) OESOPHAGECTOMY

Two Stages:

1. Laparotomy (first):
   • Gastric mobilisation (preserve right gastroepiploic + right gastric vessels)
   • Gastric tubularisation
   • Pyloroplasty / pyloromyotomy
   • Feeding jejunostomy insertion
2. Right posterolateral thoracotomy - 4th/5th ICS (second):
   • En-bloc resection of oesophagus + thoracic duct + mediastinal nodes
   • Intrathoracic oesophagogastric anastomosis

For OGJ Cancer (Siewert I/II):

• Ivor Lewis OR Extended total gastrectomy with Roux-en-Y jejunal loop
• Early disease: Proximal gastrectomy

Exam Point: Ivor Lewis = 2 incisions (abdomen FIRST, then chest). Intrathoracic anastomosis. Standard for lower-third adenocarcinoma.

OTHER SURGICAL APPROACHES (Know for MCQs)

TREATMENT BY STAGE (Must Know)

HISTOLOGY MATTERS

PALLIATION (For Inoperable / Metastatic)

• SEMS (Self-Expanding Metallic Stent) - immediate dysphagia relief; first choice
• Palliative chemotherapy (good performance status)
• Radiotherapy / brachytherapy (especially for SCC bleeding)
• Laser, dilatation, photodynamic therapy

Exam Caution: Stents in upper oesophagus risk airway compression and tracheal erosion

HIGH-YIELD EXAM POINTS SUMMARY

1. Upper third SCC → Chemoradiotherapy first (larynx preservation)
2. Middle third → McKeown (3-stage; neck anastomosis)
3. Lower third → Ivor Lewis (2-stage; intrathoracic anastomosis)
4. T1a → Endoscopic resection (EMR/ESD)
5. ≥T3/N+ → Always neoadjuvant therapy before surgery
6. SCC is radiosensitive; definitive CRT is a curative alternative
7. Transhiatal = no thoracotomy = limited nodal dissection
8. OGJ tumour epicentre ≤2 cm into gastric cardia = staged as oesophageal cancer