Ann Thorac Surg 1995;60:1340
© 1995 The Society of Thoracic Surgeons
Invited Commentary
Invited Commentary
Joseph LoCicero, III, MD
Department of Surgery, New England Deaconess Hospital, Harvard Medical School, 110 Francis St, Suite 2C, Boston, MA 02215
See also page 1337.
Data gathered over many years in lung cancer resulted in not only the establishment of a therapy-based staging system but also the initiation of well-defined surgical protocols for early-stage disease and carefully constructed trials for late stage disease. Some would argue that pretherapy staging in esophageal cancer is not so important. However, earlier detection of operable esophageal cancers, particularly in patients with Barrett's esophagus, is more commonplace. Some would argue that surgery plays no significant role in the management of esophageal cancer. Although statistics show excellent survival rates for surgical extirpation of early cancers, it is less clear for later stage disease. Unfortunately, the series used to fuel the debate contain patients who had no form of pretherapy staging, making meaningful comparisons moot. Contemplated multicenter multimodality trials will suffer the same fate without pretherapy staging. Some would argue that less-than-surgical staging such as esophageal ultrasound is accurate, thus eliminating the need for invasive approaches. We have seen a similar assault on mediastinoscopy by computed tomography, but when tested in a multicenter trial, computed tomographic scanning could do no better than 65% accuracy.
Krasna and colleagues from the Cancer and Leukemia Group B have boldly taken the first stumbling steps toward true pretherapy surgical-pathologic staging in esophageal cancer. This early series shows their frustration. Explorations were first through the left side of the chest, then the right side of the chest. Laparoscopy is a necessary component of evaluation, but few thoracic surgeons are facile enough to perform this procedure efficiently. The operating time was 2.5 hours. Their accuracy rate for this staging tour-de-force was 88%, with an accuracy of only 50% in patients with T4 disease. Despite the significant shortcomings of this innovative staging modality, it may turn out to be the best way to clearly stage patients before beginning therapy. Such information will be the only way to settle the continued argument concerning the place of surgery, chemotherapy, and radiation in the management of this cancer with such cloudy survival statistics.
Related Article
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Thoracoscopic Staging of Esophageal Cancer: A Prospective, Multiinstitutional Trial
- Mark J. Krasna, Carolyn E. Reed, Michael T. Jaklitsch, Deborah Cushing, and David J. Sugarbaker
Ann. Thorac. Surg. 1995 60: 1337-1340.
[Abstract]
[Full Text]
