Help with consultation?

paul61 said:

Tri-Modal Therapy normally has chemo/radiation first
Karrie,

First it is great that your Dad is a candidate for surgery. That is his best chance for a "cure".

Assuming your Dad has adenocarcinoma, the "gold standard" of treatment for Stage 3 esophageal cancer is "Tri-modal" therapy. This typically includes three or four rounds of chemotherapy with a three chemotherapy drug cocktail like Cisplatin, Epirubicin, and 5 FU; and approximately 28 rounds of radiation therapy at the tumor site. This is designed to reduce the size or eradicate the tumor, and pick up any stray cancer cells that may have made their way through the lymphatics in the esophagus to the lymph nodes. Once that is completed a waiting period of a few weeks is taken to allow the chemotherapy and radiation to continue to work, and for the patient to recover from the treatment. Then a scan is done to assess the effects of the treatment and assess the patient's readiness for surgery.

Surgery is then completed and after surgery the tissue removed (including the esophagus, a portion of the stomach, and a number of lymph nodes immediately adjacent to the tumor site.) are sent to pathology and evaluated of any signs of cancer cells. If active cells are found outside the esophagus (e.g. in some of the lymph nodes removed) follow up chemotherapy is recommended.

I had surgery first and then had my chemotherapy. This is not typical. Normally only Stage 1 patients go directly to surgery without chemotherapy or radiation. In my case the original staging was Stage 1 so I went directly to surgery. Once they did the pathology on the lymph nodes removed in surgery, they found active cancer cells in one of the 21 nodes removed. As a result they recommended follow up chemotherapy. I can tell you post surgical chemotherapy is much more difficult than pre-surgical chemotherapy. After surgery your Dad's digestive system will need to get used to his new "plumbing" and this has it's own set of challenges. Adding the side effects of chemotherapy makes recovery that much more challenging.

So as you go to the consult for treatment planning, I would be asking:

1. What is the pre-surgery treatment plan
2. Does my Dad has any medical issues that may affect his treatment plan or surgery?
3. What surgical approach will be used and why?
4. How many surgeries of this type does the planed surgical facility do, and what are their recovery statistics?
5. What are my Dad's possibilities for having the treatment and surgery plan evaluated by an independent second opinion?


When it comes to the surgery itself there are three major surgical options for esophageal cancer.

First the traditional Ivor Lewis (IL) approach. In this approach two large incisions are made. One in the abdomen between the belly button and sternum and one from just under the right shoulder to the middle of the patient’s back. The abdominal incision is used to release the stomach so it can be modified and moved higher to be connected to the remainder of the esophagus. The back incision is used to enter through a space in the ribs to remove a section of the esophagus and form the new connection between the remainder of the esophagus and the remainder of the stomach.

Many surgeons around the US perform this surgical approach.

This approach is the most invasive of the approaches and typically has the longest recovery time. I had this particular surgery and I was in the hospital for 12 days. The original estimate was 10 days but I got an infection in my incisions and was there an extra two days while they gave me IV antibiotics.



Second the Transhiatal Esophagectomy approach. In this approach a large incision is made in the abdomen between the belly button and sternum and a smaller incision is made in the patient’s neck. The abdominal incision is used to perform the same functions as in the IL approach described above. The incision in the neck is used to remove a section of the esophagus and to form a new connection between the remainder of the esophagus and the remainder of the stomach. A more detailed description can be found at

THE Surgery Overview

Dr. Mark B. Orringer at University of Michigan Medical Center is a leader in this surgical approach.

The in hospital recovery time for this approach is shorter than the IL approach and the recovery time is somewhat shorter.



Third the Minimally Invasive Esophagectomy (MIE) approach. In this robotically assisted approach a number of very small incisions are made in the abdomen and in the neck. The surgeon uses the robot “arms” and cameras through the small incisions to release and modify the stomach, remove a section of the esophagus and a section of the stomach and re-attach the remainder of the stomach and esophagus. A more detailed description can be found at

MIE Surgery Overview

Dr. James D. Luketich at University of Pittsburgh Cancer Institute is the leader in this surgical approach.

The in hospital recovery time for this approach is the shortest of the approaches and the recovery time is shorter as well.


There are a number of reasons why a surgeon may recommend one approach over another. The area around the esophagus has a number of lymph nodes connected into the lining of the esophagus and frequently a number of these are removed to insure a clear surgical margin around the cancer and for pathological examination to validate the staging done prior to surgery. In some cases, prior surgical scar tissue and other medical issues may dictate one approach over the other.

Be sure you understand your Dad's surgeon's reasoning for selecting one approach over the other. “I don’t do that approach” is not the answer you are looking for. This is MAJOR surgery and you want to have a surgeon that does MANY of these surgeries a year.

When I had my surgery I did not even know an MIE was available. Given my experience, if I had it to do over again I would have traveled to a major cancer center and found a surgeon who is competent in MIE.

Of course your Dad needs to be comfortable with his surgeon and insurance is sometimes an issue. But I wanted to you be aware that there are choices and you should make an informed decision.

I hope this information helps you prepare your questions for the consult.

Best Regards,

Paul Adams
McCormick, South Carolina

DX 10/22/2009 T2N1M0 Stage IIB
12/03/2009 Ivor Lewis
2/8 through 6/14/2010 Adjuvant Chemo Cisplatin, Epirubicin, 5 FU
Two year survivor

Life may not be the party we hoped for, but while we are here we might as well dance!