Prevalence and management of colorectal neoplasia in surgically treated esophageal cancer patients

Curative-Intended Management of Synchronous Esophageal and Rectal Cancer-A Systematic Literature Review

PURPOSE

Synchronous esophageal (EC) and rectal carcinoma (RC) is a rare and challenging condition, particularly in curative-intended treatment. Especially locally advanced tumors may not be suitable for primary resection and require individual multimodal treatment. This review examines curative-intended management of synchronous EC and RC.

MATERIAL AND METHODS

A systematic literature search across five electronic databases according to the PRISMA guideline was conducted. Individual patient data was analyzed, including two additional cases from our institution.

RESULTS

We identified 9 relevant cases from 1552 results. Additionally, two male patients (62 and 65 years old) from our institution were included. Both received 5-fluorouracil/cisplatin-based chemoradiotherapy (CRT) for EC. Sequential short-course radiation (SCRT) for RC was performed in one patient. After complete response (CR) in both tumors, no consecutive surgery was performed. He underwent resection for local recurrence of RC 11 months later and is currently considered as disease-free (30 months follow-up). The second patient underwent primary resection of RC and had early progression following resection of EC. We found that most patients had advanced EC (8/11), with the majority receiving neoadjuvant (5/11) or definitive treatment (3/11). Locally advanced RC was diagnosed in 5/11 patients, primarily treated with sequential resection. Pyrimidine-based systemic treatment was common. Four relapses and two deaths were reported, but median follow-up was 11 (range 1.5-30) months only.

CONCLUSION

The review suggests that neoadjuvant multimodal approaches may offer curative potential for synchronous EC and RC, with individualized treatment protocols adapted from single-cancer protocols. Nevertheless, data on long-term outcome is limited.

Synchronous multiple primary neoplasms of the esophagus, rectosigmoid and central nervous system

INTRODUCTION

Multiple primary neoplasms (MPN) are rare and can affect any system especially the upper aero-digestive system. They can be simultaneous, synchronous or metachronous. Their management depends on the individual organ system affected and simultaneous resection is possible as shown by T. Suzuki.

PRESENTATION OF CASE

We encountered a 77-year-old male who had had malena and constipation for 2 months and on investigation was found to have a rectosigmoid and an esophageal adenocarcinoma as well as a calcified lesion in the brain. He underwent surgery for the rectosigmoid growth only (according to the patient's preference) and received chemotherapy. Unfortunately, he developed acute intestinal obstruction after 2 cycles of chemotherapy and died.

DISCUSSION

MPNS are defined as presence of two or more histologically distinct tumours in the same individual. It can be synchronous or metachronous. Various factors like genetic and environmental play crucial role in its development. Management of these depends up on the status of the patient, stage of disease.

CONCLUSION

MPNS are rare but their rising trend suggests it should be kept in mind while working up a patient with any malignancy.

Successful multidisciplinary treatment for synchronous advanced esophageal and cecal cancers after total gastrectomy with reconstruction by jejunal interposition

BACKGROUND

Esophageal squamous cell carcinoma is characterized by field cancerization, wherein multiple cancers occur in the esophagus, head and neck, and stomach. Synchronous esophageal and colorectal cancers are also encountered with a certain frequency. A good prognosis can be expected if the tumors in both locations can be safely and completely removed. For patients with multiple cancers that occur simultaneously with esophageal cancer, it is necessary to perform a staged operation, taking into consideration the associated surgical invasiveness. It is also necessary to select multidisciplinary treatment depending on the degree of progression of the multiple lesions. We report our rare experience with a staged operation for a patient with synchronous advanced cancers of the esophagus and cecum who had previously undergone total gastrectomy with reconstruction by jejunal interposition for gastric cancer.

CASE PRESENTATION

A 71-year-old man with a history of reconstruction by jejunal interposition after total gastrectomy was diagnosed as having multiple synchronous esophageal and cecal cancers. After neoadjuvant chemotherapy, we performed a planned two-stage operation, with esophagectomy and jejunostomy in the first stage and ileocecal resection and jejunal reconstruction with vascular anastomosis in the second. Postoperatively, the patient was relieved without major complications, and both tumors were amenable to curative pathologic resection.

CONCLUSIONS

Our procedure reported here may be recommended as an option for staged resection and reconstruction in patients with simultaneous advanced esophageal and cecal cancer after total gastrectomy.

Importance of colonoscopy in patients undergoing endoscopic resection for superficial esophageal squamous cell carcinoma

BACKGROUND

The aim of the study was to clarify the frequency of colorectal neoplasm (CRN) complicating superficial esophageal squamous cell carcinoma (ESCC) and the need for colonoscopy.

METHODS

We retrospectively reviewed 101 patients who had undergone initial endoscopic resection (ER) for superficial ESCC. Control group participants were age- and sex-matched asymptomatic subjects screened at our hospital over the same period of time. Advanced adenoma was defined as an adenoma ≥10 mm, with villous features, or high-grade dysplasia. Advanced CRN referred to advanced adenoma or cancer. We measured the incidence of advanced CRN in superficial ESCC and controls, and we compared the characteristics of superficial ESCC patients with and without advanced CRN.

RESULTS

In the superficial ESCC group, advanced CRNs were found in 17 patients (16.8%). A history of smoking alone was found to be a significant risk factor of advanced CRN [odds ratio 6.02 (95% CI 1.30-27.8), P=0.005].

CONCLUSION

The frequency of synchronous advanced CRN is high in superficial ESCC patients subjected to ER. Colonoscopy should be highly considered for most patients who undergo ER for superficial ESCC with a history of smoking, and is recommended even in superficial ESCC patients.

Incidence and risk factors of synchronous colorectal cancer in patients with esophageal cancer: an analysis of 480 consecutive colonoscopies before surgery

BACKGROUND

The precise incidence rates of multiple primary colorectal cancers in esophageal cancer patients are unknown.

METHODS

In total, 480 consecutive patients with esophageal cancers surgically resected in the Kumamoto University Hospital received preoperative total colonoscopy for the assessment of colorectal disease between April 2005 and February 2016. We retrospectively investigated the occurrence of synchronous colorectal cancer with esophageal cancer. In addition, we examined the risk factors for the incidence of multiple primary colorectal cancers.

RESULTS

Of the 480 patients, 14 (2.9 %) had synchronous colorectal cancers, 13 had well-differentiated tubular adenocarcinomas, and 1 had papillary adenocarcinoma. Other 14 patients had metachronous colorectal cancer. The current incidence rates of synchronous and total (both synchronous and metachronous) colorectal cancers outnumbered those in normal healthy population and those in esophageal cancer patients which previously reported by The Japan Esophageal Society. The age ≥70 years (hazard ratio 4.82, 95 % confidence interval 1.473-15.78; p = 0.009) and Brinkman index ≥800 (hazard ratio 3.47, 95 % confidence interval 1.056-11.37; p = 0.040) were the independent risk factors for the incidence of synchronous colorectal cancer. They were also the independent risk factors for the incidence of total colorectal cancer.

CONCLUSIONS

The results of the present study suggested that pretreatment screening with total colonoscopy is meaningful for patients with esophageal cancer, because the frequency of synchronous colorectal cancer was not negligible. Particularly, in patients >70 years and with history of heavy smoking, pretreatment colonoscopy might be necessary.