Preemptive surgery for premalignant foregut lesions

Abstract

Introduction: Preemptive surgery is the prophylactic removal of an organ at high risk for malignant transformation or the resection of a precancerous or "early" malignant neoplasm in an individual with a hereditary predisposition to cancer. Recent advances in molecular diagnostic techniques have improved our understanding of the biologic behavior of these conditions. Predictive testing is an emerging field that attempts to assess the potential risk of cancer development in predisposed individuals. Despite substantial improvement in these forms of testing, all results are imperfect. This information often becomes an important tool that is used by healthcare providers to evaluate the risk-benefit ratio of various risk modifying strategies (i.e., intensive surveillance or preemptive surgery).

Methods: A systematic literature review was performed using Medline and the bibliographies of all referenced publications to identify articles relating to preemptive surgery for premalignant foregut lesions.

Results and discussion: In this review, we outline the controversies surrounding predictive risk assessment, surveillance strategies, and preemptive surgery in the management of high-grade dysplasia (HGD) in Barrett's esophagus (BE), hereditary diffuse gastric cancer (HDGC), bile duct cysts, primary sclerosing cholangitis (PSC), and pancreatic cystic neoplasms. Resection of BE is supported by the progressive nature of the disease, the risk of occult carcinoma, and the lethality of esophageal cancer. Prophylactic total gastrectomy for HDGC appears reasonable in the absence of accurate screening tests but must be balanced by the impact of surgical complications and altered quality of life. Surgical resection of biliary cysts theoretically eliminates the exposed epithelium to decrease the lifetime risk of cholangiocarcinoma. Liver transplantation for PSC remains controversial given the scarcity of donor organs and inability to accurately identify high-risk individuals. Given the uncertain natural history of pancreatic cystic neoplasms, the merits of selective versus obligatory resection will continue to be debated.

Conclusions: Preemptive operations require optimal judgment and surgical precision to maximize function and enhance survival. Ultimately, balancing the risk of surgical intervention with less invasive interventions or observation must be individualized on a case-by-case basis.