Carcinoma of the esophagus: twelve years' experience with a philosophy for palliation

Impact of chemotherapy on prognosis of resectable pathological T3N0M0 esophageal cancer patients: a population-based study

Aims: This study aimed to retrospectively determine the influence factors and survival effects of chemotherapy in pathological T3N0M0 esophageal cancer (EC) patients based on histological type. Methods: A total of 1136 pathological T3N0M0 EC patients who had surgery were chosen from the Surveillance, Epidemiology and End Results database. The patients were divided into subgroups based on histological type and chemotherapy status. Multivariate logistic regression, log-rank test and Cox regression were used to identify prognostic risk factors and survival differences. A propensity score matching analysis was applied to adjust the covariates. The impact of additional chemotherapy was also assessed in patients who had postoperative radiotherapy. Results: The 5-year overall survival was 36.4% for all patients. Chemotherapy was an independent protective factor of survival in both adenocarcinoma and squamous cell carcinoma patients. In the survival analysis, chemotherapy significantly improved the prognosis of EC patients, both for adenocarcinoma and squamous cell carcinoma. Propensity score matching analysis validated these results. Conclusion: Chemotherapy is recommended for pathological T3N0M0 EC patients regardless of histological type.

Characteristics of esophagorespiratory fistulas resulting from esophageal cancers: a single-center study on 243 cases in a 20-year period. World J Surg. 2009;33:994-1001. [PMID: 19288038 DOI: 10.1007/s00268-009-9988-3]

BACKGROUND

Esophagorespiratory fistulas are serious complications of esophageal tumors. The main goal of this study was to reveal their characteristics.

METHODS

In the period between 1984 and 2004, 243 fistulas were diagnosed among the 1993 patients with esophageal cancer. Comparing the characteristic data of patients with and without fistula (demographics, symptoms, duration time of symptoms, morphologic features, histology, metastases, staging), multivariance analysis showed significant differences (P < 0.05). Patients with fistula were divided into two additional groups (I, n = 82; II, n = 161 cases) with cluster analysis. The difference between these two groups was also significant.

RESULTS

It was possible to perform a palliative endoscopic intubation in 176 cases, while 62 patients could be treated only supportively. The average survival was 3.4 and 1.2 months, respectively. Fistula was a late complication of tumor in two thirds (66.3%) of the cases, while in 33.7% it was diagnosed in younger patients at the early stage of the disease, with a more aggressive, less differentiated histology. In these patients the weight loss, the grade of dysphagia, and the size of the tumor were smaller, the possibilities of treatment were fewer, and survival time was shorter (2.1 vs. 3.1 months).

CONCLUSIONS

These tumors seem to be specific forms of esophageal cancers. For a better quality of life and longer survival time for these patients, there should be earlier diagnosis and endoscopic intubation as the best palliative treatment should be performed.

[Pathological characteristics of esophago-respiratory fistulas of esophageal tumor origin]

Esophago-respiratory fistulas, evolving as a result of esophageal tumors, are serious and lethal complications on account of the constant respiratory contamination and the inability to swallow. They can develop either as the complication of the end stage disease or sometimes even in the first stage of the malignancy. The objective was to reveal the characteristics of the disease. In a prospective single-center study in the period between 1984 and 2004, 243 fistulas were diagnosed. Their data were analyzed using multivariate analysis. The mean age of patients with fistula was 56.9 years, the male-to-female ratio was 4.3:1. The average time of the complaints was 5.2 months, while the time of manifestation of the fistula was 7.5 months. Dysphagia was diagnosed in 97.5% of the patients, fever in 36.9%, and cachexia in 59.5%, respectively. The average loss of weight was 10.4 kg and the average size of the tumor was 7.7 cm. Endoscopic intubation was performed in 176 cases. The average survival was 3.4 months. Patients with fistula were divided into two groups, where the characteristics of the disease were significantly different. Only in 66.3% was the fistula a late complication. In the other 33.7% of the cases the fistula was diagnosed in younger patients at the early stage of the disease, with a more aggressive, less differentiated histology. In these patients the weight loss, the grade of dysphagia and the size of the tumor were smaller, the possibilities of treatment were fewer, and survival were shorter.

An audit of postoperative radiotherapy after non-curative resection for cancer of the oesophagus

AIMS

The role of postoperative radiotherapy (PORT) after non-curative resections for cancer oesophagus is not well defined. A policy of offering PORT after non-curative resections for cancer oesophagus has been followed at our institution, and we report an audit of our experience.

MATERIAL AND METHODS

Between March 1990 and September 2002, 139 patients underwent resections for cancer oesophagus. Of these, 86 patients received PORT to a dose of 45-50.4 Gy/25-28 fractions. Eleven of these patients also received concurrent and adjuvant 5-fluorouracil (5-FU). Disease-free survival and overall survival were computed from the day of surgery using the Kaplan-Meier method.

RESULTS

Seventy-six per cent (65/86) of patients had squamous cell carcinoma and 69% (59/86) of patients had tumours in the lower-third of the oesophagus. The median interval between surgery and PORT was 41 days, and 93% of patients received doses as planned. Strictures at the anastomotic site and ulcerations in the stomach mucosa were seen in 17% and 5% of patients, respectively. The median and 5-year disease-free survival was 12 months (95% CI 9.9-14.1) and 14%; whereas the median and 5-year overall survival was 17 months (95% CI 12.4-21.6) and 17%, respectively. Local and distant failures were seen in 29% and 45% of patients, respectively.

CONCLUSIONS

PORT, after a non-curative resection of cancer oesophagus, is well tolerated with acceptable morbidity and survival.

Changes in the surgical management of esophageal cancer from 1970 to 1993

PURPOSE

To evaluate the changes since 1970 in the management and outcome of esophageal resection for cancer.

METHODS

The records of all 316 patients who underwent esophageal resection for cancer at University of California Los Angeles Medical Center during the years 1970 to 1993 were reviewed.

RESULTS

When records from 1984 to 1993 were compared to those from 1970 to 1983, significant decreases were seen in operative mortality (10% to 3%, P < 0.01), morbidity (72% to 60%, P < 0.05), anastomotic leaks (12% to 5%, P < 0.03), and reoperations (20% to 8%, P < 0.003). Time spent in hospital and in intensive care decreased 40%. These improvements in short-term outcome were most evident in patients with disease in later stages. The 5-year survival rate increased (12% to 21%, P < 0.01). A greater percentage of tumors presented in early stages (21% versus 37%).

CONCLUSIONS

Short-term outcome of surgical resection for esophageal carcinoma improved between 1970 and 1993, in part because of changes in perioperative and surgical management. Long-term survival improved, probably due to earlier detection of tumors.

Adjuvant postoperative radiation therapy after curative resection of squamous cell carcinoma of the thoracic esophagus: a prospective randomized study

Postoperative radiation therapy following curative resection of squamous cell carcinoma of the esophagus was investigated in a prospective randomized study. A group of 33 patients received postoperative radiation therapy and were compared to a control group of 35 patients treated by surgery alone. No statistically significant differences were noted between the two treatment groups concerning overall and disease-free survival rates. Postoperative irradiation significantly increased the incidence of fibrotic strictures of the esophagogastric or esophagocolonic anastomoses and caused a delayed recovery of patients quality of life. Based on these results, we believe that postoperative radiation therapy alone cannot be advocated as a adjuvant therapy following curative resection of squamous cell carcinoma of the esophagus.

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.

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

The choice of treatment for patients with cancer of the esophagus and cardia is controversial. Since overall survival is poor, the most important aim of treatment should be improvement of the main complaint: the inability to eat. In a retrospective analysis of 265 patients, referred to the University Hospital in Leiden, The Netherlands, comparisons were made between palliative effects of surgical resection (N = 92) and irradiation (N = 128). Several methods of comparing surgery with irradiation are possible: (1) all surgical patients vs. all irradiated patients; (2) only those surgical patients who survived the operation (N = 70) vs. all irradiated patients (N = 128); and (3) survivors after resection (N = 70) vs. only those irradiated patients treated with "curative" radiation (N = 62). Analysis of prognostic factors showed that in both surgical and irradiated patients, the only statistically significant factor was the (dis)ability to eat. Criteria to be considered to make individual recommendations for either treatment are presented.

Surgical therapy of oesophageal carcinoma

During the past 10 years, postoperative mortality associated with surgical treatment of oesophageal carcinoma has been reduced by one-half. However, it appears that all efforts to improve long-term survival with extensive excisional procedures and adjuvant chemotherapy and radiotherapy have failed. Fifty-six of 100 patients presenting to the surgeon with an oesophageal carcinoma have resectable disease. Recent studies suggest that seven of them will die from postoperative complications and 49 patients will be discharged from the hospital after an average of 3 weeks. Of these patients, 27 will survive the first, 12 the second, and ten the fifth year. Although it may be possible to further reduce postoperative complications and mortality, the chances of improving the long-term prognosis of patients with oesophageal carcinoma seem small.

Heat, drugs, and radiation given in combination is palliative for unresectable esophageal cancer

From April 1966 to April 1986, 101 men and women with unresectable squamous cell carcinoma of the esophagus were treated in our clinic. Since 1983, 21 were treated with a combination of hyperthermia, chemotherapy, and radiotherapy (group I). Before 1983, for another 80 patients, radiation plus chemotherapy had been prescribed (group II). Nine of 21 patients in group I had an unresectable carcinoma due to an advanced tumor, 9 had an associated severe clinical status, and 3 refused surgery. Out of 80 in group II, 50 had a far advanced tumor, 21 had a poor clinical condition, and 9 refused operation. With regard to staging, for 21 in group I, 6 were classified as Stage I, 5 as Stage II, 7 as Stage III, and 3 as Stage IV. As to the 80 in group II, those in Stage I, II, III, and IV accounted for 8, 22, 39, and 11, respectively. The median doses of each modality, for patients in group I, were 6 times of hyperthermia at 42-45 degrees C for 30 minutes, 40 Gy of X ray and 30 mg of bleomycin. For patients in group II, a median dose of 56 Gy of X ray was given. Response rates determined by esophagograms and endoscopies for the patients in groups I and II were 76.2% (16/21; 4 CRs, 12 PRs) and 39.2% (31/79; 2 Crs, 29 PRs), respectively (p less than 0.001). The effective rates determined by improvement in quality of life (relief of pain and dysphagia) for groups I and II were 61.9% and 37.2%, respectively. A longer survival was obtained for patients in group I (median survival: 9 months vs 6 months). Especially for the patients classified as Stage I, a significantly longer survival was obtained with a combination of hyperthermia, chemotherapy, and radiotherapy (p less than 0.01).

Transhiatal esophagectomy for carcinoma of the esophagus: experience with 26 patients

Transhiatal esophagectomy was performed in 26 patients with esophageal carcinoma. The patients were selected for this procedure by means of transhiatal palpation of the tumor at laparotomy. Twenty had squamous cell carcinoma and 6, adenocarcinoma. The tumor locations were the upper third in 8, middle third in 12, and lower third in 6. On postoperative staging, 15 patients had Stage III and 6, Stage IV neoplasms. Among 25 elective resections there was 1 hospital death, which was due to severe coronary artery disease. One patient who had an urgent resection for a perforated carcinoma died of multisystem failure 32 days postoperatively. Complications included splenic injury requiring splenectomy in 5 patients; tracheal laceration in 2 patients (only 1 requiring a thoracotomy); azygos vein laceration requiring sternotomy for repair in 1 patient; chylothorax in 1; recurrent laryngeal nerve paralysis in 3 (temporary in 2); and transient anastomotic leaks in 3. Five patients had pneumonia with transient respiratory failure. Twelve of the operative survivors died of cancer 3.2 to 32 months postoperatively, and 12 are alive 3 to 28 months after operation. The actuarial survival is 53 +/- 11% (+/- standard error) at one year and 46 +/- 12% at two years. Transhiatal esophagectomy is a reasonable, safe operation that should be considered for tumors at all levels of the esophagus.

Colon interposition in the treatment of carcinoma of the esophagus and gastric cardia

The stomach is the organ most used for restoring esophageal continuity after esophageal resection for malignancy. In the present series, we report our experience over a 20-year period (1965 through 1984) with an alternative method, colon interposition. Two hundred forty-eight patients (124 men and 124 women) underwent colon interposition. Seventy-one percent (175) of the tumors were squamous cell carcinomas, and 23% (58) were adenocarcinomas in the gastric cardia and lower esophagus. The left colon was the substitute of first choice and was used in 54% of the patients. Of the interpositions, 59% were antiperistaltic. Esophagectomy without thoracotomy was the method in 146 patients. The operative mortality was 16% (40 patients), and 3% (8 patients) sustained colon graft necrosis. Leakage in the upper anastomosis occurred in 4% (10). No dysphagia was experienced by 85%, 80%, and 76% of the patients during reexaminations 3, 6, and 12 months, respectively, after operation. The 1-year and 5-year survival for patients with squamous cell carcinoma was 40% and 10%, respectively, and for patients with adenocarcinoma, 50% and 12%, respectively. The data from this study suggest that colon interposition offers a good alternative for long-term relief of dysphagia in patients with carcinoma of the esophagus. The rate of complications is acceptable.

Transthoracic versus extrathoracic esophagectomy: mortality, morbidity, and long-term survival

Extrathoracic esophagectomy for carcinoma is an acceptable substitute for transthoracic resection if it can be shown to have comparable or superior safety and no adverse effect on long-term survival. To test this hypothesis, we employed extrathoracic esophagectomy in 30 consecutive patients with carcinoma of the esophagus from January, 1978, to July, 1984. During this period, 65 comparable patients underwent transthoracic resection through a left thoracotomy for lower esophageal lesions or a right thoracotomy and laparotomy for upper thoracic lesions. Only patients with carcinoma limited to the gastric cardia were excluded from the study. Overall morbidity was higher in the extrathoracic than in the transthoracic group (13 of 30 or 43.3% versus 15 of 65 or 23.1%; p = 0.05), but the differences in hospital mortality (4 of 65 or 6.2% for the transthoracic group versus 4 of 30 or 13.3% for the extrathoracic group) and duration of hospital stay (17.4 +/- 11.7 days for the transthoracic group versus 20.5 +/- 13.4 days for the extrathoracic group) were not statistically significant. Considering all patients who either died or sustained a postoperative complication, we found significant differences favoring transthoracic resection in those subgroups of patients who were able to undergo primary reconstruction at the time of resection (12 of 57 or 21.1% versus 15 of 28 or 53.6%; p = 0.004), those with advanced Stage III lesions (11 of 47 or 23.4% versus 12 of 20 or 60%; p = 0.006), those with tumor of the lower esophagus (8 of 35 or 22.9% versus 6 of 10 or 60%; p = 0.04), and those with tumor that could be resected through a left thoracotomy (2 of 18 or 11.1% versus 17 of 30 or 56.7%; p = 0.002). Actuarial survival curves for all transthoracic and extrathoracic resections and separate analysis for Stage I and Stage III tumors revealed no statistically significant differences between these two techniques.

Palliation of esophageal malignancy with photoradiation therapy

Seven patients with severe or complete obstruction of the esophagus by malignancy were treated with photoradiation after presensitization of the tumor with intravenous hematoporphyrin derivative. The 625- to 635-nm therapeutic light was delivered from a tunable dye argon laser system coupled through quartz fibers, passed through the biopsy channel of a flexible esophagoscope, with local anesthesia. All tumors (adeno, squamous, and melanoma) responded, and swallowing was improved. Although tumor is still present, one patient is 11 months from initial treatment and is eating a regular diet. Another patient is 8 months from initial treatment and has no dysphagia. One patient died of aspiration of gastric tube feedings and 3 others died of their disease at 3 weeks, 3 months, and 6 months, respectively, from their initial treatment. Another patient died 11 months from his initial treatment due to a cardiac arrhythmia. During the 11 months after his initial treatment he continued to eat a regular diet.

Esophagogastrectomy as palliative treatment for esophageal carcinoma: results obtained in the setting of a thoracic surgery residency program

The palliative treatment of esophageal carcinoma has included intubation, bypass, dilation, irradiation, and esophagogastrectomy. The last has been criticized by some on the basis of high operative morbidity and mortality. To assess the success of this method at our institution, we reviewed the 60 consecutive resections performed for carcinoma of the esophagus from January, 1972, through June, 1983. Forty-six patients had squamous cell tumors and 14, adenocarcinomas. There were 47 men and 13 women, and the mean age was 59.9 years (range, 38.5 to 78.9 years). The most frequent preoperative findings included dysphagia (55), weight loss (34), chest pain (22), and vomiting (49). Fifty (83%) out of the 60 resections were performed by the resident staff under the supervision of an attending surgeon. Four patients died within 30 days of operation, an operative mortality of 6.7%. Immediate causes of death included respiratory failure, myocardial infarction, hemorrhage, and renal failure. One of the patients who died and 3 of the survivors had an anastomotic leak. There were 27 additional complications in 24 patients: respiratory problems (8), arrhythmias (5), pleural effusion (4), gastric outlet obstruction (2), wound infection (2), and 1 each of pulmonary embolus, acute brain syndrome, congestive heart failure, myocardial infarction, chylothorax, and empyema. The one-, two-, three-, and five-year actuarial survival rates were 46%, 27%, 10%, and 5%, respectively. Mean survival for the 46 patients dead at the time of this study was 13.5 months. Outpatient follow-up data were available on 53 (95%) of the operative survivors and showed an absence of dysphagia in 87.5% during most of the follow-up period.(ABSTRACT TRUNCATED AT 250 WORDS)