Upper GI Cancer Tumor Treatment & Surgery

Once a diagnosis is obtained, or confirmed, treatment depends on the type and stage of your gastro-esophageal/upper GI cancer. Options usually include endoscopic procedures like Endoscopic Mucosal Resection, laparoscopic or open surgery, chemotherapy, radiation therapy or a combination of these treatment modalities together.

Accurate staging of any tumor is paramount. Especially true for esophageal conditions like high grade dysplasia in Barret’s or intramucosal carcinoma, as early stage tumors can sometimes be treated endoscopically (EMR). Endoscopic resection can also be used to determine the exact T stage of the tumor. Once the exact T stage is determined, a decision is made about further treatment. Surgery is a possibility.

Similarly to esophageal cancer, early stage gastric cancer can be treated endoscopically (EMR), or surgically without upfront chemotherapy. This decision is made after appropriate staging workup is done, with upper GI endoscopy with biopsies, endoscopic ultrasound, cat scans, and sometimes pet scans. EMR can yield the most accurate local staging. T1a tumors can be treated with EMR only; T1 B tumors usually require formal surgical resection as the risk of lymph node involvement with T1 b tumors is much higher. Early stage gastric tumors treated with EMR only require frequent visits with endoscopic surveillance locally in addition to cat scans for systemic surveillance. T1b tumors usually require formal surgical resection with lymph node dissection.

If a tumor penetrates into the esophageal wall deeper (T2 and above) or there is evidence or strong suspicion of regional nodal involvement, preoperative treatment with a chemotherapy, radiation, or most commonly a combination of both is usually indicated. This is also called neoadjuvant treatment of locally advanced esophageal cancer. A five to 6 week treatment course is followed by additional imaging studies as part of what we call restaging. If we find no new sites of disease during restaging we offer surgery.

Upfront treatment of certain larger tumors or locally advanced malignancies frequently results in downstaging of the tumor. Downstaging can convert inoperable tumors to operable tumors, or more extensive operations to less extensive surgeries.

A landmark study from Europe published in the New England Journal of Medicine in 2012 found that patients treated with neoadjuvant therapy and surgery had a near doubling in overall survival compared to the surgery alone arm in the setting of locally advanced esophageal cancer.

Gastro-esophageal tumors are located at the gastero-esophageal junction. This is a very common location for distal esophageal cancers or proximal gastric cancers. These malignancies can behave more like gastric cancer or more like esophageal carcinoma. Distinguishing between the two entities can be difficult. We use radiographic , endoscopic and pathologic clues. Depending on the stage, these tumors may or may not require preoperative treatment. Locally advanced GE cancers can be treated similar to gastric cancers (usually preoperative chemotherapy) or similar to esophageal cancers (usually preoperative chemo-radiation). Similarly, these tumors may require a proximal/total gastrectomy versus a formal esophagectomy, depending on how high the proximal extension of the tumor is in the esophagus. This is part of the intraoperative decision making and we rely heavily on intraoperative endoscopy, performed in the operating room after the patient goes to sleep.

For the most accurate staging we prefer to perform and an EUS for all gastric cancers. This information helps us determine if a tumor should be considered locally advanced. Other signs of locally advanced tumors are enlarged lymph nodes on various imaging studies potentially harboring regional metastasis. Once a locally advanced gastric cancer is identified, most patients will receive neoadjuvant therapy, likely using systemic chemotherapy sometimes combined with radiation. Selected patients may undergo diagnostic laparoscopy prior to a final treatment plan being rendered. We strongly believe in the importance of peritoneal washings for all patients diagnosed with gastric cancer.

• Esophagectomy (laparoscopic and open)
• Transhiatal esophagectomy
• Ivor-Lewis esophagectomy
• Selective abdominal lymphadenectomy for upper GI malignancies
• Partial gastrectomy (laparoscopic and open)
• Distal gastrectomy (laparoscopic and open)
• Proximal gastrectomy (laparoscopic and open)
• Total gastrectomy
• Small bowel resection
• Feeding tube insertion

We perform laparoscopic surgery using minimally invasive techniques whenever possible. That means potentially less pain, less blood loss and reduced need for blood transfusions. Laparoscopic surgery could also mean a shorter hospital stay, with a quicker recovery and faster return to normal daily activities. However, there are potential downsides of laparoscopic surgery as well. In addition, not everybody is a candidate for laparoscopic gastro-esophageal surgery. Tumor size, location, previous medical and surgical history all weigh into this decision making process. Your candidacy for laparoscopic procedures is discussed with you by your surgeon in details.