The choice between surgical resection and radiation therapy for patients with cancer of the esophagus and cardia: a retrospective comparison between two treatments

Squamous cell carcinoma of the buccal mucosa involving the masticator space: a case report

Squamous cell carcinoma of the buccal mucosa has an aggressive nature, as it grows rapidly and penetrates well with a high recurrence rate. If cancers originating from the buccal mucosa invade adjacent anatomical structures, surgical tumor resection becomes more challenging, thus raising specific considerations for reconstruction relative to the extent of resection. The present case describes the surgical management of a 58-year-old man who presented with persistent ulceration of the mucosal membrane and a mouth-opening limitation of 11 mm. Diagnostic imaging revealed a buccal mucosa tumor that had invaded the retroantral space upward with involvement of the anterior border of the masseter muscle by the lateral part of the tumor. In this report, we present the surgical approach we used to access the masticator space behind the maxillary sinus and discuss how to manage possible damage to Stensen's duct during resection of buccal mucosa tumors.

Thoracic esophageal carcinoma above the carina: a more formidable adversary?

BACKGROUND

Prognosis with esophageal carcinoma above the carina is generally thought to be the worst without any conclusive demonstration.

METHODS

Clinicopathologic features of 101 patients with thoracic esophageal carcinoma above the carina (AC group) were compared with those of 665 patients with a tumor below this level (BC group).

RESULTS

The number of T4 tumor was significantly larger in the AC group (P < 0.001). Survival curve for all patients in the AC group was significantly worse than the BC group (P < 0.001). Survival in patients who underwent any treatment other than esophagectomy was equally bad in the two groups. However, survival in patients undergoing esophagectomy was similar in the two groups (P = 0.64), with the cumulative 5-year survival rates of 44.5% and 43.1%, respectively. Even in patients with metastatic disease in the lymph nodes, the cumulative 5-year survival rates after radical esophagectomy were similar.

CONCLUSIONS

The prognosis of patients in the AC group is generally worse than the BC group because of the close anatomical relationship with the tracheobronchial tree. However, radical esophagectomy is recommended for patients at stages less advanced than T4.

Diagnosis and treatment of esophageal neoplasms

During the last 10 years, the diagnosis and treatment of esophageal carcinoma have improved considerably. Endoscopy with Lugol staining and endoscopic ultrasonography have been newly introduced and used for early diagnosis and more accurate tumor staging. As a result, the number of patients with tumors at an early stage has increased remarkably (superficial carcinoma, 23%). In the field of treatment, surgical results have improved not only in the short term (30-day mortality rate, 4%) but also in the long term (5-year survival rate, 30%). The field of operation has been extended (3-field lymph node dissection), with lower morbidity and mortality. On the other hand, some techniques for limited treatment such as endoscopic mucosal resection, intraluminal radiotherapy, and laser irradiation have been introduced for the treatment of esophageal carcinoma at an early stage with curative intent. However, there are still many patients with esophageal carcinoma at an advanced stage for whom these treatments fail or are futile. The role of radiotherapy has been made more significant by the introduction of brachytherapy or in combination with other treatment modalities such as surgery, chemotherapy and hyperthermia. Response rates for existing anticancer drugs used as a single agent are 0-38%. Chemotherapy appears to have created significant improvements when used in combined modalities (response rate, 16-76%). However, chemotherapy for patients with esophageal carcinoma still offers an unsatisfactory survival benefit and remains experimental. Studies to evaluate multimodality treatments using chemotherapy, combined with radiotherapy and/or surgery have started. The contribution of molecular biology to the diagnosis and treatment of this disease is a subject for future investigation.

Advanced esophageal carcinoma

From 1976 until 1990 a total of 212 patients with squamous cell carcinoma of the thoracic esophagus were referred for surgical treatment. Resectability was 84.1% (161 of 191). Actuarial 5-year survival in patients with negative lymph nodes was 51.2% versus 12.4% in lymph node-positive patients. Therefore advanced carcinoma was defined to compromise all patients with involved regional (N1) or distal lymph nodes (M+Ly) as well as patients with T4 tumors or solid organ metastasis (M+org) irrespective of their lymph node status. Comparing complete (R0) versus incomplete (R1-R2) resections for stage III and IV carcinoma revealed 20% and 0% five-year survivals, respectively. There was no 5-year survival in the stage IV group. When excluding solid organ metastasis, the median survival shifted from 8.5 months after incomplete (R1-R2) to 20 months after complete (R0) resection. In 1991 three-field lymphadenectomy was initiated that included bilateral cervical lymphadenectomy. Thirty-seven patients have been treated so far (23 squamous cell carcinoma, 14 adenocarcinomas). Cervical lymph nodes were positive in 24.3% with an incidence up to 28.5% for distal-third carcinoma. Subsequently, 6 patients (16%) moved from M0 to M+Ly status. Our results confirm the key role of surgery not only in improving survival and locoregional tumor control but in refining the accuracy of staging advanced carcinomas provided complete resection is possible.(ABSTRACT TRUNCATED AT 250 WORDS)

Esophageal cancer, early disease: diagnosis and current treatment

Most esophageal cancers are at a fairly advanced stage at the time of diagnosis, and curative therapy is not possible. For those that are detected early, cure may be possible, particularly if there is no lymphatic spread. Radical therapeutic approaches result in increased treatment-related mortality, high treatment-induced morbidity, and reduced quality of life. Therefore it is one of the major targets in the treatment of esophageal cancers to classify the tumor and to perform adequate stage-related therapy. The modern diagnostic procedures, such as endoscopy, endoluminal sonography, computed tomography (CT) scanning, and endoscopic biopsy, have led to major advances in preoperative staging. Endoluminal sonography is able to predict the depth of tumor infiltration in the esophageal wall and the existence of local lymph node metastasis, whereas CT scanning demonstrates distant metastasis. Histologic classification of the tumor together with genetic and cell biologic characteristics can predict the prognosis. Currently, the best prospect for cure of early esophageal cancer is surgical resection through the abdominothoracic approach, although less radical surgical procedures such as transhiatal resection without extensive lymph node dissection seem to achieve the same results. Even less traumatic is the use of minimal invasive techniques, which certainly will be used more often in the future. For early esophageal cancers limited to the epithelium and the lamina propria, local destruction of the tumor leads to long-term survival and cure. Techniques such as endoscopic resection, laser coagulation, photo-dynamic laser activation, and argon beam exposure have been described and seem to achieve similar results.(ABSTRACT TRUNCATED AT 250 WORDS)

Combined external beam and low dose rate intraluminal radiotherapy in oesophageal cancer

Thirty-five patients with oesophageal cancer were treated with external beam irradiation (50-60 Gy) followed by a boost-dose of 15-20 Gy by means of low dose rate intraluminal brachytherapy. Of the 35 patients treated 17 (48%) were pretreated with laser therapy or dilation alone. Although the intraluminal application time was long (up to 36 h) the treatment was feasible with minor acute toxicity. The palliative effect of the combined treatment was excellent; a 6 weeks post-treatment 32 of the 35 patients were able to eat solid food. Late complications were seen in six patients (17%), of which only one was severe and probably treatment-related. The median survival was 11 months; the 1- and 2-year survival were 42% and 10% respectively. The survival was strongly dependent on local control. Distant metastases became evident in 23% of patients. The interval between external radiotherapy and brachytherapy seemed to be critical. The results were compared with 68 historical controls. A significantly better survival was observed at 6 months. It is concluded that low dose rate intraluminal brachytherapy is a useful and feasible technique to increase the total dose for obtaining a better local control. The shortcomings are discussed and ideas for further improvement are mentioned.