Carcinoma of the esophagus

Therapy of Advanced Esophageal Cancer with Bleomycin, Irradiation and Combination of Bleomycin with Irradiation

Results from treating 51 patients with advanced esophageal cancer are presented. Fifteen patients were treated with Bleomycin, 12 with radiotherapy, and 24 with a combination of Bleomycin and radiotherapy. The best results were achieved in the group of patients treated with combined therapy showing 62% objective remissions (15/24) which was statistically significant (P < 0.001) in comparison to the other groups. In the Bleomycin therapy group, there were 26% objective remissions (4/15), and in the group treated only with radiotherapy 33% (4/12). The median duration of remission was 9 months in the combined therapy group, 6.3 months in the group treated with radiotherapy, and 2.6 months in the Bleomycin treated group. The authors concluded that the combination of Bleomycin and radiotherapy seems to be a further step in palliative treatment of advanced esophageal cancer.

Current Results of Esophageal Cancer Surgery. Time Trends in Operative Mortality and Long Term Survival

This paper represents a historical analysis of the results achieved by esophageal cancer surgery over the last three decades, as they appear in the literature of the years 1954–1985, and in our own experience between 1965 and 1985, with the aim of assessing the evolution of operative mortality and long-term survival. In a review of 4930 resections reported in western literature, mean values of perioperative mortality went down from 30 % to 9 %, while the five-year survival increased from 8 % to 19 %. Similar changes were evident in Japanese and Chinese literature where the survival rose from 9 % to 23 % in unscreened populations and up to 90 % in early cancers. In our experience, dividing the series in two decades (1965–74 and 1975–85), the overall perioperative mortality changed from 28 % to 13 %. The actuarial survival for the two periods was 8 % vs 18 % at 5 years, with a median survival of 9 and 18 months. A greater difference was evident for NO patients where the survival rose from 15 % to 35 % at 5 years, with a median survival of 15 vs 38 months.

Induction chemotherapy in the treatment of patients with carcinoma of the esophagus

A prospective randomized phase III trial was carried out at Songklanagarind Hospital from August 1988 to December 1990. The objectives of the study were to evaluate the effect of chemotherapy regimen in squamous cell carcinoma of the esophagus and to determine whether induction chemotherapy improves symptom-free period and survival in these patients compared to surgical treatment alone. Twenty-four patients were randomized to receive 2 cycles of chemotherapy, cis-platinum 100 mg/m2 intravenously on day 1, bleomycin 10 mg/m2 loading dose on day 3, followed by 10 mg/m2/day continuous intravenous infusion on days 4 through 7, and vinblastine 3 mg/m2 given intravenously on days 1, 8, 15, 22. The cycle was repeated on day 29. Fifteen patients completed 2 courses of chemotherapy and among these, 2 patients had a complete clinical response (13%), 6 (40%) had a partial response, and 7 patients (47%) had no response. Four patients died during chemotherapy treatment. Grade 3 hematologic toxicity (ECOG criteria) was observed in 47% (7/15) of patients. Twenty-two patients were randomized to conventional treatment (surgery alone). Median survival time was 17 months in both groups. However, early survival appeared to be better in the control group. Kaplan-Meier survivals at 6 months were 69% and 89% and at 3 years were 31% and 36% for the induction chemotherapy group and control group, respectively. The survival time differences were not statistically significant (P = 0.186). These findings demonstrate that although this chemotherapy regimen had some effect on squamous cell carcinoma of esophagus, it did not improve survival. On the contrary, survival seems to be better in the control group. The 6-month survival discrepancy between both groups might be due to the poor nutritional status of our patients, who may better tolerate smaller dosages of chemotherapy.

Prolonged chemotherapy for localised squamous carcinoma of the oesophagus

We evaluated the feasibility of six courses of chemotherapy in 34 consecutive patients with localised squamous cell carcinoma of the oesophagus. All 32 evaluable patients first received at least two courses of chemotherapy. There were 18 patients with resectable carcinomas who underwent surgery and 14 patients with unresectable carcinomas who received definitive chemoradiotherapy. After two courses of 5-fluorouracil and cisplatin 21 (66%) of 32 patients had either a complete or major response. A median of five courses (range, 1-6 courses) was administered. 17 out of 18 (94%) patients with resectable carcinoma had a 'curative' resection (negative proximal, distal, and radial margins by histopathology in an en-block resection specimen) and 2 patients had a complete pathological response. The median survival duration of all patients was 28 months (range, 2-46+ months). The median survival duration of 14 patients with unresectable carcinoma was 23 months (range, 8-36+ months), and the median survival duration of 18 patients with resectable carcinoma has not been reached at a median follow-up of 24+ months (range, 10+ to 46+ months). No deaths occurred because of chemotherapy or chemoradiation therapy. Our data suggest that prolonged chemotherapy is feasible in patients with locoregional squamous carcinoma of the oesophagus. An ongoing controlled trial will determine the contribution of chemotherapy to patients' survival.

Esophageal carcinoma metastatic to the stomach. A clinicopathologic study of 35 cases

Esophageal carcinoma metastatic to the stomach was analyzed in 35 patients. Ten were discovered in surgical specimens and 25 at autopsy. All patients were men with a mean age of 62 years. Primary lesions were most frequently located in the middle of thoracic esophagus and were larger than 7 cm. Undifferentiated carcinoma was found in 29% of the patients. Local spread of the primary lesions to neighboring structures was seen in 34%. Lymphatic invasion, and intramural metastases within the esophagus, as well as lymph node metastases, were predominant. Metastatic lesions within the stomach were mostly located in the gastric cardia, were less than 2 cm or more than 4 cm in size, and resembled submucosal tumors. Gastric metastases occasionally spread from the submucosa to neighboring structures. In spite of aggressive treatment, the prognosis was extremely poor because of multiple spread of carcinoma to local regions, lymph nodes, and distant organs. The clinicopathologic characteristics of this disease and possible treatment are discussed.

Esophageal carcinoma metastatic to the stomach. A clinicopathologic study of 35 cases

Esophageal carcinoma metastatic to the stomach was analyzed in 35 patients. Ten were discovered in surgical specimens and 25 at autopsy. All patients were men with a mean age of 62 years. Primary lesions were most frequently located in the middle of thoracic esophagus and were larger than 7 cm. Undifferentiated carcinoma was found in 29% of the patients. Local spread of the primary lesions to neighboring structures was seen in 34%. Lymphatic invasion, and intramural metastases within the esophagus, as well as lymph node metastases, were predominant. Metastatic lesions within the stomach were mostly located in the gastric cardia, were less than 2 cm or more than 4 cm in size, and resembled submucosal tumors. Gastric metastases occasionally spread from the submucosa to neighboring structures. In spite of aggressive treatment, the prognosis was extremely poor because of multiple spread of carcinoma to local regions, lymph nodes, and distant organs. The clinicopathologic characteristics of this disease and possible treatment are discussed.

Cisplatin, vindesine, and bleomycin chemotherapy of local-regional and advanced esophageal carcinoma

Seventy-one patients with epidermoid carcinoma of the esophagus were treated with a three-drug combination of cisplatin, vindesine, and bleomycin. Forty-five patients had local-regional tumor and received chemotherapy prior to surgery or radiation therapy. Twenty-six patients with extensive disease were treated primarily with chemotherapy alone. The overall major objective response rate to cisplatin-vindesine-bleomycin was 53 percent (36 of 68 evaluable patients). Patients with local-regional disease had a higher response rate than those with extensive disease (63 and 33 percent, respectively). Following preoperative chemotherapy, 34 patients with local-regional disease underwent exploration. Resectable disease was present in 82 percent. There was no increase in operative morbidity or mortality (5.6 percent), when compared with historical control groups. The median survival for the preoperative chemotherapy group was 16.2 months, which is superior to that of a historical control group (p = 0.023). For patients with extensive disease, treated primarily with chemotherapy alone, the median duration of response was seven months. Toxicities of cisplatin-vindesine-bleomycin were in general well-tolerated, and included nausea and vomiting (seen less frequently because of extensive use of metoclopramide), alopecia, nephrotoxicity, and peripheral neuropathy. The dose-limiting toxicity was myelosuppression. Although conventional chemotherapeutic agents have little activity, these results indicate that the investigational combination of cisplatin, vindesine, and bleomycin can induce major regressions in a substantial proportion of patients with esophageal cancer. When this drug combination is used preoperatively, high resection rates and possibly improved survival are seen.

Treatment of esophageal carcinoma combined preoperative chemotherapy

Thirty-four patients with epidermoid carcinoma of the esophagus received a triple-drug regimen preoperatively consisting of cisplatin, vindesine, and bleomycin. Partial response to chemotherapy (greater than 50% reduction in measurable tumor size with concomitant improvement in swallowing function) was noted in 65% of the patients. Of the 34 patients, 28 (82%) had resectable disease. A one-stage high esophagogastrectomy utilizing the end-to-end anastomosis stapling device was performed on all 28 patients. Operation was followed by external radiation therapy to the esophageal bed, to a tumor dose of 5,500 rads delivered in 5 weeks. The postoperative median follow-up is now 14 months (range, 7 to 36 months). Thirteen patients are alive and well, and 10 patients have relapsed, 4 of whom are still alive with disease. Two patients died of postoperative complications, and 1 death was drug related. On the other hand, 5 of the 6 patients with unresected tumors died within 5 months. While the preliminary results are encouraging, longer follow-up will be required to determine whether the response rate to chemotherapy will result in a longer disease-free interval and longer survival.

Autopsy findings in squamous-cell carcinoma of the esophagus

The findings at autopsy of 79 patients with esophageal carcinoma over a period of 15 years were reviewed. Five patients were free of tumor, and another seven had disease localized to the esophagus and other mediastinal structures. Sixty-seven (85%) had metastatic disease. The average number of metastatic sites per patient was 3.3. Most common metastatic sites were lymph nodes (73%), lung (52%), and liver (47%). The patients in this series had a higher incidence of metastases than those in other published series. Possible reasons for this discrepancy include race and sex differences between this population and those in previous reports, as well as the fact that this series includes very few postoperative deaths.

Combination chemotherapy of esophageal carcinoma using cisplatin, vindesine, and bleomycin

Sixty-one patients with epidermoid carcinoma of the esophagus have been treated with a three drug combination of cisplatin, vindesine, and bleomycin. Of 53 patients currently evaluable for response, 29 (55%) have had partial remissions: 7/16 with metastatic, and 22/37 with local-regional disease. The median duration of response in metastatic patients is eight months. Of 28 patients treated preoperatively, 23 (82%) had resectable disease. The major toxicities seen were nephrotoxicity and myelosuppression. Cisplatin, vindesine and bleomycin is an effective combination in the treatment of esophageal carcinoma. Effects on long-term survival cannot yet be evaluated.

Combined modality therapy of esophageal carcinoma

One hundred ten patients with epidermoid carcinoma of the esophagus were treated at the Memorial Sloan-Kettering Cancer Center (MSKCC) with combined modality techniques involving preoperative irradiation (RT) and surgery, and with preoperative chemotherapy (CT), surgery, and irradiation. For the 76 patients receiving preoperative RT during the period 1965-1976, the overall resectability rate was 54% with an operative mortality of 12%; long-term survivors (greater than 3 years) were few (7%). For 34 patients receiving preoperative CT with cisplatin and bleomycin, major objective tumor regression (greater than 50%) was seen by day 18 in 20%, with an additional 44% having smaller but definite improvement in the barium esophagram and in swallowing function. Of those receiving preoperative CT, 76% had resectable lesions, with an operative mortality of 11%. The median follow-up for this group is 24 months; of the 30 patients followed for at least 12 months, 20% are alive without evidence of disease. Although the resection rate following preoperative chemotherapy seems to be higher, thus allowing better palliation, neither preoperative radiation nor chemotherapy with cisplatin and bleomycin have had a major impact on long-term survival.

Oesophageal squamous cell carcinoma: I. A critical review of surgery

Authors writing an oesophageal cancer include adenocarcinoma to a variable extent--between 1 and 75 per cent--but the true incidence of this histological type is about 1 per cent. Most adenocarcinomas are gastric in origin, involving the lower oesophagus, have a lower operative mortality than in the middle or upper one-third of the oesophagus and poorer prognosis than squamous cell carcinoma, but there is no alternative treatment to surgery. Squamous cell carcinoma of the oesophagus, separated incompletely but as far as possible, has been analysed by reviewing data on 83 783 patients in 122 paERS. After trying to standardize the data, it appears that of 100 patients with the condition, 58 will be explored and 39 have the tumour resected, of whom 13 will die in hospital. Of the 26 patients leaving hospital with the tumour excised, 18 will survive for 1 year, 9 for 2 years and 4 for 5 years. Oesophageal resection for squamous cell carcinoma has the highest operative mortality of any routinely performed surgical procedure today.

Combination of bleomycin and adriamycin with and without radiation on the treatment of inoperable esophageal cancer. A randomized study

In a prospective randomized study, 31 patients with inoperable esophageal cancer were treated with a combination of bleomycin and adriamycin, and with a combination of these cytostatics and radiation. Evaluation of treatment results showed 3 partial remissions and 2 stable-disease cases in the group of 16 patients treated by cytostatic drugs alone; in all other cases, the disease progressed. The response rate achieved in this group was 19%. In the group including 15 patients who were irradiated with a dose of 3600--4000 rad and received simultaneously the same cytostatics with a somewhat lower dose of adriamycin, there were 3 complete remissions, 6 partial remissions, and 4 stable-disease cases, while in 2 cases the disease progressed. The response rate was 60%, which was statistically significant (P less than 0.025) when compared with the results achieved by the group receiving the bleomycin adriamycin combination. The average duration of remissions in the complete-response cases was 11 months, and in the partial-response cases, 5.2 months with combined treatment, and 4.2 months with combination chemotherapy. The toxic side-effects were tolerable for the patients, albeit more intensive with the combined-treatment modality. Four esophagobronchial fistulas (four disease progressions) and one rupture of the aorta were noted during treatment. This study has shown the advantages of chemoradiotherapeutic treatment of inoperable esophageal cancer.

Carcinoma of the gastroesophageal junction. A ten year experience with esophagogastrectomy

Eighty-six patients with carcinoma of the gastroesophageal junction were treated between 1966 and 1976. Adenocarcinoma was present in 62 patients and squamous cell carcinoma in 24. Surgical exploration was performed on 68 patients (79%) and 52 lesions (60%) were resected by combined midline laparotomy and right thoracotomy. There were 6 deaths (11%), 2 due to anastomotic leak. The mean survival for all resected patients was 2.1 years with a 22% three year life table survival (10/52). Five of 14 patients with negative nodes are alive more than five years. Palliative resection in 17 patients resulted in a mean survival of 10.5 months and no five year survivals. Esophagogastrectomy utilizing the Lewis technic reduces operative mortality and extends survival for patients with carcinoma of the gastroesophageal junction.