Randomized clinical trial on the combination of preoperative irradiation and surgery in the treatment of esophageal carcinoma: report on 206 patients

From June 1977 to May 1985, a prospective randomized clinical trial on pre-operative radiation for esophageal carcinoma was carried out in 206 patients. Lesions under 8 cm in length and patients younger than 65 years, at least on semi-liquid diet and not contra-indicated for surgery were randomized into a combined group (104 patients) or a surgery alone group (102 patients). Eight MV X ray units were used for the pre-operative radiation using A-P portals to deliver 4,000 cGy to the whole mediastinum and the left gastroepiploic lymphatic chain. Surgery was carried out after 2 to 4 week's rest. The immediate results of the combined group and the surgery alone group were: resection rate 93% and 85%, operative mortality 5% and 6%, intra-thoracic anastomotic leak 0% and 1%, positive pathology at the esophageal stump 0% and 2%, and lymph nodes metastasis 27% and 35% respectively. The 5-year survival rates of the combined group and the surgery alone group were 35% and 30%. We have noticed that those patients with lesions showing radiation reaction of grade III gave a 5-year survival of 50% (12/24). Because intra- and extra-thoracic lymphnode metastasis caused failures (41% and 34% of these two groups), increasing the preoperative tumor dose to 60 Gy or designing post-operative irradiation to cover the bilateral supraclavicular areas was necessary. The whole mediastinum and the left gastroepiploic lymphatics could further improve the results of surgery. Further studies are needed.

[Sister chromatid exchanges (SCE), chromosomal aberrations and micronuclei of cultured peripheral lymphocytes in patients with lung cancer, miners and non-mining workers of the tin mine in Yunnan]

Determination of SCE frequency, chromosomal aberration and micronucleus rate of cultured peripheral lymphocytes in 32 patients with lung cancer, 33 miners and 40 non-mining workers in Yunnan Tin Mine was carried out. The results showed that the cancer patients had higher SCE incidence, chromosomal aberration and micronucleus rate, the non-mining workers had the least and miners on an intermediate level. There was a significant difference of SCE, chromosomal aberrations and micronucleus rate between patients and non-mining workers (P less than 0.05-0.01). We also found that miners had a significant higher SCE and chromosomal aberration rate but not micronucleus rate as compared with the non-mining workers. We proposed that some carcinogens present in the Yunnan Tin Mine be responsible for the genetic damages in the miners. Chemical drugs may be considered to contribute to the genetic damage in cancer patients who had a tendency toward an increased SCE, chromosomal aberration and micronucleus rate as compared to the miners, though without reaching a statistical significance. We suggested that combination assay of SCE with chromosomal aberration or micronucleus be an useful index for screening of the high risk population and monitoring the chemical drug prevention of lung cancers in Yunnan Tin Mine.

[Experience in the surgical treatment of 748 patients with lung cancer]

A series of 748 patients with lung cancer as treated by surgery from 1961 to 1984 is reported. Regular lobectomy was done in 445 (74%) patients, bronchoplastic lobectomy in 67 (11.2%), segmental or wedge excision in 15 (2.5%) and pneumonectomy in 74 (12.3%) in which the ratio of left to right pneumonectomy was 2.9:1. Overall resection rate was 80.4% (601/748) and resection mortality was 1.2% (7/601) (death within 30 days of operation). Overall 5 year survival rate was 42% (169/402). The 5 year survival rate was 35.3% for pneumonectomy, 54.1% for bronchoplastic lobectomy, 42.3% for regular lobectomy and 16.7% for segmental or wedge excision. In this analysis, emphasis is laid to the therapeutic validity of the different modes of surgery. Statistical data show that only when the indication of different surgical interventions are strictly adhered to and the reasonable procedures are carried out, could better results be obtained. In surgical treatment of lung cancer, it is an important principle to eradicate the tumor and its metastatic foci as thorough as possible and to conserve the respiratory function as much as possible. Regular lobectomy has now become the "standard" and first choice operation. Pneumonectomy should be reserved for the patients with absolute necessity due to the extent of the lesion, adequate cardiopulmonary function and possibility of a permanent cure. Pneumonectomy is substituted by bronchoplastic lobectomy to a certain degree, preserving more of the lung function and improving the living quality after operation and long term results. Extensive practice of this surgical modality is advised.

Surgery of esophageal carcinoma

The experience of surgical treatment in 1,874 patients with carcinoma of the esophagus seen at the Cancer Institute and Hospital of the Chinese Academy of Medical Sciences, Beijing, People's Republic of China, between 1958 and 1982, is reported. Despite the prevalence of this malignancy in this part of China, only 3% of the patients in this series had stage I disease, while 80% of the patients had either stage III or stage IV disease with extraesophageal tumor invasion and regional or distant metastases. Of the entire series there was an overall resectability rate of 83.9%, being 77.6% between 1958 and 1969 and 89.0% between 1970 and 1982. Among the 1,572 resections of the entire series, there were 66 deaths within 30 days of operation, for a resection mortality rate of 4.2%, being 4.9% between 1958 and 1969 and 3.7% between 1970 and 1982. Anastomotic leakage occurred in 67 cases of the 1,572 resections, for an incidence of 4.3%. Of the 67 cases with anastomotic leaks, 38 recovered after intensive treatment; the remaining 29 died eventually of the complication, giving a death rate of 43.3%. Pathologic studies of the 1,572 specimens showed lymph node metastasis in 46.1% of the cases. It is obvious that practically all the unresectable cases showed more extensive lymph node involvement at operation, although fixation of the tumor with severe invasion to the surrounding organs usually constituted the chief cause of unresectability. The postresection long-term survivals as calculated by the number of resections at 5, 10, and 15 years were 30.2% (390/1293), 22.4% (196/876), and 18.9% (112/594), respectively. Over one-third, or 36.8%, of the 1,874 patients in the present series were treated with a combination therapy of preoperative irradiation and surgery. The results in the group of 408 selective patients and those in the group of 83 randomized patients with midthoracic esophageal carcinomas were gratifying. In the latter group there was a resectability rate of 95.2%, a resection mortality rate of 3.8%, an incidence of intrathoracic anastomotic leakage of 0%, and a 5-year survival rate of 45.5%, as compared to 89.6%, 4.3%, 1.7%, and 25%, respectively, in the control group treated by surgery alone. From these findings it is concluded that preoperative irradiation as an adjunct can promote both the immediate and long-term results of surgery for carcinoma of the esophagus. Recent advances in the surgical treatment of carcinoma of the esophagus may change the pessimistic philosophy for this malignancy.(ABSTRACT TRUNCATED AT 400 WORDS)