Role of esophagectomy in treatment of esophageal carcinoma with clinical evidence of adjacent organ invasion

With carcinoma of the thoracic esophagus, clinical evidence of invasion of adjacent organs (T4) indicates a highly advanced stage, and most surgeons a void esophagectomy. Although the therapeutic strategy for such disease is g enerally selected based on preoperative evaluation and intraoperative inspe ction, their accuracy and the relation to survival outcomes after esophagec tomy have seldom been analyzed on the basis of exact histopathologic eviden ce. We performed esophagectomy, with perioperative adjuvant therapy when po ssible, on patients with clinical-T4 tumors unless absolutely unresectable conditions were detected. Among the 500 patients who underwent esophagectom y, the 78 patients whose tumors were confirmed to be T4 pathologically were compared with patients whose tumors were assessed as T4 preoperatively or intraoperatively to evaluate the role of esophagectomy for clinical-T4 carc inoma. Esophagectomy was possible for 99% of the pathologic-T4 tumors preop eratively assessed as resectable, but the resection was grossly incomplete in 35%. The true-positive rates in tumors preoperatively and intraoperative ly assessed as T4 were 51% and 84%, respectively. The hospital mortality ra te in patients with pathologic-M tumors was 4%. The overall 5-year survival rate for patients with pathologic-T4 tumors was 14%, compared with 60% for those with tumors assessed as T4 intraoperatively but not pathologically. Esophagectomy with perioperative adjuvant therapy yielded occasional cure w ith an acceptable mortality rate for patients with pathologic-T4 tumors ass essed as technically resectable. Preoperative assessment and intraoperative macroscopic inspection had limitations for predicting pathologic-T4 diseas e and incomplete resection. Only patients with definitive evidence of unres ectability should be excluded from esophagectomy.