With
carcinoma of the thoracic esophagus, clinical evidence of invasion of adjacent organs (T4) indicates a highly advanced stage, and most surgeons avoid
esophagectomy. Although the therapeutic strategy for such disease is generally selected based on preoperative evaluation and intraoperative inspection, their accuracy and the relation to survival outcomes after
esophagectomy have seldom been analyzed on the basis of exact histopathologic evidence. We performed
esophagectomy, with perioperative adjuvant
therapy when possible, on patients with clinical-T4
tumors unless absolutely unresectable conditions were detected. Among the 500 patients who underwent
esophagectomy, 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
carcinoma.
Esophagectomy was possible for 99% of the pathologic-T4
tumors preoperatively assessed as resectable, but the resection was grossly incomplete in 35%. The true-positive rates in
tumors preoperatively and intraoperatively assessed as T4 were 51% and 84%, respectively. The hospital mortality rate in patients with pathologic-T4
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 with an acceptable mortality rate for patients with pathologic-T4
tumors assessed as technically resectable. Preoperative assessment and intraoperative macroscopic inspection had limitations for predicting pathologic-T4 disease and incomplete resection. Only patients with definitive evidence of unresectability should be excluded from
esophagectomy.