Role of preoperative administration of bleomycin and radiation in the treatment of esophageal cancer

Clinical results of treatment of advanced esophageal carcinoma with hyperthermia in combination with chemoradiotherapy

Chemoradiotherapy combined with hyperthermia was administered to 35 patients with advanced esophageal carcinoma who either required preoperative treatment or had nonresectable disease. As a rule, each patient received a total dose of 30 Gy in 15 daily fractions of 2 Gy, 5 d/wk. Bleomycin or cisplatin, in combination with fluorouracil, was employed as chemotherapy. Hyperthermia was applied by intraluminal heating twice a week for a total of six sessions using an apparatus (IH-500T; Japan Crescent Co Ltd; Tokyo, Japan) (radiofrequency, 13.56 MHz) with an intraesophageal applicator and two extracorporeal applicators placed on the chest and back. This treatment method obtained a response rate of 80%, consisting of a complete response rate of 22.9% and partial response of 57.1%. In 15 cases, the tumor became resectable (resectability rate, 42.9%) following treatment. The histologic study of the resected specimens revealed absence of viable tumor cells in five patients (33.3% of the resected cases) (markedly effective), and in six patients (40.0%), the combined therapy was considered to be moderately effective. No complications considered due to hyperthermia itself were recognized. The overall 5-year survival rate was 11.8%. In conclusion, chemoradiotherapy combined with hyperthermia was locally effective, yielding an overall response of 80.0%. However, the prognosis of the patients remains unfavorable. Advanced esophageal carcinoma requires treatment taking into account lymphatic and hematogenic metastasis at the beginning of treatment.

Adjuvant therapies for cancer of the thoracic esophagus

During the past four decades, especially in recent years, various active adjuvant therapies combined with surgery have improved the outcome in cases of cancer of the esophagus. However, no optimum adjuvant therapy has been determined. From 1981 to 1992, 341 patients with regional and distant node metastasis who underwent curative surgery were treated with postoperative radiotherapy (RT), postoperative radiochemotherapy (RC), and postoperative aggressive chemotherapy (AGC) in a controlled study in our department of surgery. Five-year survival rates, including operative deaths and unrelated diseases of the former group, were 0% for RT, 19.9% for surgery alone, 39.8% for RC, and 48.2% for AGC. Such rates for the latter group were 6.8% for AGC, 13.3% for surgery alone, and 33.3% for RC. In addition, results of a group study on the effectiveness of three-field node dissection in 715 cases of thoracic esophageal carcinoma by 10 institutions were analyzed. This analysis showed that there were no differences in the 5-year survival rate of curative surgery in cases with positive nodes among the groups treated with surgery alone (SA), with postoperative radiotherapy (PR), and with postoperative chemotherapy (PC). As to the 91 cases with positive cervical nodes, the 3-year survival rates in cases treated with SA (n = 22), PR (n = 20), and PC (n = 49) were 25.3%, 48.1%, and 53.6%, respectively; a significant improvement of survival in these patients. Summaries of studies of preoperative or postoperative radiotherapy, and both multimodal therapies are introduced.

High dose external beam radiation therapy with or without concomitant chemotherapy for esophageal carcinoma

Esophageal cancer patients treated with radiotherapy (RTx) are most often those with malignancies too extensive for surgery or those who deemed medically unsuitable for an aggressive surgical approach. Summarizing RTx series, the 2-year survival rate is in the range of 10% and at 5 years about 5%. Although not randomly compared, these results are not significantly worse than those achieved with surgery in more advanced tumors. In stage I/II tumors, more recent trials reported of 5-year survival rates varying between 12% and 20%. These data indicate that irradiation may be administered with curative intention but usually only for patients who are also candidates for primary surgery. On the other hand, modern RTx (doses > 60 Gy) +/- endoluminal after-loading may provide good palliation (relief of dysphagia) for patients with good prognostic factors such as weight loss of less than 10% body weight, good performance status, younger age, and location of the tumor. In the perioperative setting, RTx reduced the frequency of the local recurrences but did not increase the overall resection and R0 resection rates and did not improve survival due to more patients relapsing at distant sites. Combined chemoradiotherapy has shown to be superior to RTx alone with respect to local control, disease free survival and overall survival and in a marked reduction of distant failures. These data support the use of chemoradiotherapy as standard treatment of locally advanced and nonresectable esophageal cancer. They also provide a basis for randomized trials comparing chemoradiotherapy alone versus preoperative treatment modalities.

Combined treatment modalities in esophageal cancer. Should chemotherapy be included?

The poor prognosis of esophageal carcinoma patients after treatment with local modalities (surgery/radiotherapy) is well known. The purpose of this review is to assess the question whether addition of chemotherapy to local treatment of squamous cell carcinoma of the esophagus has had any beneficial effect on treatment results. In the absence of a sufficient number of randomized trials addressing this issue, data mainly from single-arm studies are discussed. Compiled data from studies on preoperative chemotherapy, preoperative chemoradiation and chemoradiation without surgery suggest that addition of chemotherapy to local treatment (surgery/radiotherapy) might increase short-term survival (2 years) compared to local therapy alone. In the case of chemoradiation without surgery this conclusion is strengthened by results from randomized trials. In general lack of long-term follow-up data limits conclusion whether to recommend the inclusion of chemotherapy into treatment of esophageal cancer or not. Treatment results, however, from studies utilizing combination chemotherapy given concomitant with radiotherapy support the contention that well-designed randomized trials with long-term follow-up should be performed. Outside controlled trials, however, surgery or radiotherapy should still be regarded as standard treatment modalities.

Cisplatin, 5-fluorouracil, mitomycin C, and concurrent radiation therapy with and without esophogectomy for esophageal carcinoma

Twenty-nine patients with carcinoma of the esophagus were treated with 5-fluorouracil (5-FU) (1000 mg/m2/d as a continuous intravenous [IV]infusion on days 1 through 4), cisplatin (100 mg/m2 IV on day 1), mitomycin C (10 mg/m2 IV on day 1), and concurrent radiation therapy (4500 cGy/4.5 wk). If no disease progression was observed, operable patients underwent surgery 4 to 6 weeks after completion of radiation therapy. A thoracotomy with a gastric pull-through operation was performed in the first six patients. Subsequently, a transhiatal ("blunt") esophagectomy was used. Twenty-five patients had squamous cell histology and four had adenocarcinoma. Of 25 patients with squamous cell carcinoma, 13 underwent esophagectomy. The clinical complete response rate was 61% (eight of 13 patients), with a pathologic complete remission documented in five of 13 patients (38%). The overall local tumor sterilization rate was 53% (seven of 13 patients). In the 12 patients who did not undergo surgery after chemoradiotherapy, four had a complete clinical response (33%) and five had a partial response (41%). Symptoms or signs of local disease recurrence or stricture were noticed in ten of 12 patients who did not undergo surgery (83%), compared with 28% of patients who underwent surgery. The median survival time of the group receiving surgery was 10 months, compared with 5 months for those who did not undergo operation (P = 0.027). Patients undergoing transhiatal esophagectomy had shorter postoperative hospital stays and fewer serious complications, compared with patients undergoing transthoracic esophagectomy. The use of chemoradiotherapy and transhiatal esophagectomy for esophageal carcinoma should be evaluated using alternative sequences of treatment (e.g., postoperative therapy) to reduce toxicity while maintaining local control of disease.

Treatment of esophageal cancer: the continued need for surgical resection

We conclude that preoperative radiotherapy and chemotherapy is very likely to improve the length of survival in patients with squamous cell carcinoma undergoing surgical resection and decreases the incidence of symptomatic local recurrence requiring additional palliative treatment. A favorable tumor response to adjuvant therapy, however, did not significantly improve the survival curves in our study, does not guarantee complete tumor regression, and should not be cited as a basis for elimination of esophagectomy in treatment protocols. Adenocarcinoma treated with surgical resection has a better prognosis than similarly treated squamous cell carcinoma, but has a poorer prognosis than squamous cell carcinoma treated with preoperative adjuvant therapy and surgical resection.

Combined modality therapy for esophageal squamous cell carcinoma

Of 55 patients with esophageal squamous cell carcinoma, 30 with localized disease were treated with a combined modality for curative intent. Treatment consisted of mitomycin C (10 mg/m2 day 1) and continuous infusion 5-FU (1000 mg/m2 day, days 1-4, 29-32) (CT), radiation (XRT) (3000 rad, days 1-21) with nutritional support, and surgery (days 49-64). Surgery consisted of celiotomy, esophagectomy and esophagogastrostomy +/- postoperative ventilatory support. Postoperative CT plus an additional 2000 rad XRT was restricted to patients with histologic positive tumor. Since five resected patients with subclinical metastatic tumor had an inferior survival equal to 25 patients treated essentially for palliation, pretreatment celiotomy seems warranted to identify patients with an inferior prognosis. Of 18 resected patients without disseminated tumor evaluable for this combined modality: six were tumor free, three had intramural and nine transmural tumor; the median survival is 76 weeks and five of six living patients are disease free at 95-190 weeks; and local recurrence occurred in two and in two of seven unresected patients. Since toxicity was minimal except for postoperative pneumonitis (13%) and local recurrence low (13%), two courses of chemotherapy and 5000 rad XRT perhaps obviates the need for resection.

Postoperative long-term immunochemotherapy for esophageal carcinoma. 5 year survival

Two groups of patients with esophageal carcinoma were studied retrospectively: Group I as controls, included 50 patients who underwent esophageal resection mainly combined with preoperative radiation therapy during the period from 1965 to 1971; and Group 2 included 83 patients who were given the same treatment plus post-operative radiation and adjuvant postoperative long-term cancer immunochemotherapy during the period from 1972-1979. The one, two and five-year survival rates were 32.0, 14.0 and 12.0 per cent in Group 1, and 55.4, 35.8 and 21.5 per cent in Group 2 respectively. There were significant differences in one-year (p less than 0.02) and two-year (p less than 0.05) survival rates between the two groups. We also found that adjuvant therapy was effective in patients with no lymph node metastasis, while it was less effective in those with lymph node metastases.

Submucosal esophagography: a new method for demonstrating the depth of invasion of esophageal cancer

We developed a new method to determine the depth of esophageal cancer invasion prior to surgery. According to this method, a fiberoptic esophagoscope is used to insert a double cannula into the biopsy canal and the submucosal layer is punctured and fixed by the needle at the tip of the inner cannula through which iodized oil fluid is injected into the submucosal layer. After this procedure, plain films of the posterior mediastinum and an esophagogram are taken in at least four different directions at 24 hour, three and seven day intervals. Seventy one esophageal cancer patients were examined with this method in order to determine the depth of invasion, and whether the adventitia was involved. In three cases the method failed due to technical difficulties and in 14 surgical treatment was not indicated. In 50 of the 54 remaining patients who underwent surgery, preoperative results obtained by using this method coincided well with operative findings. Our findings strongly indicate that this method is diagnostically highly accurate in determining the surgical procedure to be used. Furthermore, this method was proven very useful in obtaining a differential diagnosis of the malignancy of submucosal esophageal tumors,