Abstracts
1997 Digestive Disease Week

Laparoscopic staging of esophageal cancer alters neoadjuvant therapy.

M Talamini*, M Kutka*, R Heitmiller*, H Kaufman*, W Flood§, A Forastiere§. Departments of *Surgery and §Oncology, Johns Hopkins Medical Institutions, Baltimore, MD.

Introduction: Neoadjuvant chemoradiation (NAC) followed by resection appears to improve outcome for esophageal cancer patients. Accurate pretherapy staging is important in selecting patients for combined modality therapy. Previously patients were entered into our NAC protocol using clinical, non-pathologic staging (CT, endoscopy, etc.). The purpose of this study was to determine whether laparoscopic evaluation prior to NAC would more precisely stage esophageal cancer patients and/or alter the treatment plan. Laparoscopy can directly evaluate spread to the tissues and regional lymph nodes associated with the increasingly prevelant adenocarcinoma of the esophagus. We also aimed to provide enteral access for nutrition.

Methods: Over 20 months 31 consecutive patients presenting with distal esophageal carcinoma were evalulated for our NAC protocol. The laparoscopic protocol consisted of exploratory laparoscopy, superior gastric lymph node biopsy, placement of jejunostomy feeding tube, and placement of Hickman catheter. Results were compared to pre-laparoscopic stage as determined by CT scan and endoscopy with ultrasound (EUS).

Results: Mean patient age was 60, and 16% were female. Significant weight loss was present in 55%. A history of reflux was present in 66%, Barrett's changes were present in 45%, and 17% had a hiatal hernia. The initial diagnosis was made by EGD in 56% and by UGI in 44%. The tissue diagnosis was adenocarcinoma in 94% and squamous carcinoma in 6%. At laparoscopy tissue was biopsied in 71%, a laparoscopic Jejunostomy (J) feeding tube was placed in 74%, and a Hickman intravenous catheter was placed in 90%. Disease not demonstrated radiographically (tumor spread into abdomen or positive lymph node biopsy) was detected in 68% of patients. TMN stage was increased in 39%, and was decreased in 22% as a result of laparoscopy. Four patients (13%) underwent resection early as opposed to receiving NAC due to findings at laparoscopy. Two patients (6%) were found to be unresectable at laparoscopy and were given palliative chemoradiation. The radiation field was enlarged in 12 of the 24 (50%) patients who underwent NAC because of laparoscopic findings.

Conclusions: Laparoscopy prior to NAC is valuable for: 1) accurate histologic abdominal staging (61% changed TMN stage) relative to standard staging and EUS, 2) appropriate triage of patients to NAC, early surgery, or palliative Rx, 3) tailoring radiation therapy to visual findings, and 4) providing access for enteral nutritional support during NAC. Laparoscopy should be used to stage esophageal adenocarcinoma.