Palliation of esophageal cancer--operative resection versus laser and afterloading therapy

Combined endoluminal and external irradiation of inoperable oesophageal carcinoma

PURPOSE

Higher radiation doses to oesophageal cancer might be possible by the steep dose gradient of an afterloading source. Structures at risk are not impaired by endoesophageal brachytherapy. Our experiences with endoesophageal afterloading in combination with external beam treatment are reported.

METHODS AND MATERIALS

Fifty-four patients were treated by this technique. All patients suffered from an inoperable oesophageal carcinoma (7 adenocarcinoma, 47 squamous-cell carcinoma). Patients were scheduled by tumour stage and medical condition into a curative group (21 patients) and into a palliative group (33 patients). Mean sum doses of 60.3 Gy (range 58-70 Gy) percutaneously and an additional endoluminal dose of 13.6 Gy (range 10-20 Gy) were applied endoluminally in the curative group and 44.9 Gy (range 14-53 Gy) plus 17.5 Gy (range 5-30 Gy), respectively, in the palliative group. Overall treatment time was 10 weeks (range 4.6-14.3 weeks) for the curative group and 9.3 weeks (range 4.1-13.9 weeks) for the palliative group.

RESULTS

Six weeks after the end of therapy a radiological remission could be observed in 32/33 of the palliatively treated patients (10 complete, 22 partial, 1 none). In 13 patients of this group a local progression was observed after a median time of 7.1 months. Median survival of this group was 9 months. A radiological remission occurred in 18/21 of the curatively treated patients (11 complete, 7 partial, 3 none). Median time to local progression (12 patients) was 4.5 months in this group and median survival was 7.7 months. The difference in time to progression reached a significant level (P = 0.05). The only favourable factors for survival were an incomplete or complete radiological remission (median survival 7.5 versus 11.4 months, P = 0.003) and stage I/II or III/IV (median survival 7.4 versus 12.6 months, P = 0.0024). The prior estimation of the treatment goal was not confirmed by survival data (curative, 7.7 months versus palliative, 9.0 months (not significant)). Eight of 54 minor and 8/54 (15%) major adverse events were observed. In four of these patients major complications were caused by progressive tumour.

CONCLUSIONS

Endoesophageal afterloading combination with percutaneous irradiation is a feasible save treatment in inoperable cases. A good local tumour regression and functional results can be reached. The data suggest that higher endoluminal doses extend the time to local progression. In comparison with the literature survival can not be increased by this treatment technique. The best way to combine both treatment modalities has not yet been found.

Surgical palliation of head and neck cancer

Palliative care in head and neck cancer has not been studied systematically. Patients with incurable head and neck tumors may live months and even years. Ideal palliation should enable them to engage in a normal life before death ensues. It is likely that our improving ability to treat these tumors without achieving cures will cause people to live longer with their cancer. Hence, the need for palliation will probably increase. Also, treatments that cure patients produce conditions that require palliation. Achievement of the best possible function is the major consideration in dealing with head and neck tumors. Difficulty with speech, swallowing, oral hygiene, and laodorous tumors are all common. Depression too should be addressed in a comprehensive fashion by the "head and neck team". The surgeon, radiotherapist, and medical oncologist will need help from dentists, prosthodontists, dental hygienists, psychiatrists, physiatrists, occupational and physical therapists, visiting nurses, nutritionists, and social workers. Palliative care in the hospital is the least desirable, although often unavoidable. Proper hospice support will benefit patients and their families.

Esophageal cancer

Esophageal cancer is an important problem in the United States. It results in more deaths (over 10,000 annually) than rectal cancer. Furthermore, the incidence of esophageal adenocarcinoma is increasing at a rate faster than that of nearly any other cancer and the reasons for the increase are not well understood. A variety of tumor-suppressor genes (including p53, APC, DCC and Rb) and proto-oncogenes (including prad1, EGFR, c-erb-2 and TGF alpha) may be involved in the development and progression of esophageal cancer. Clinical prognostic factors include stage, Karnofsky performance status, sex, age, anatomic location of the tumor, and degree of weight loss. A new staging system based on depth of wall penetration and lymph node involvement correlates well with prognosis for patients undergoing esophagectomy. Newer staging procedures including endoscopic ultrasound as well as the use of minimally invasive surgery, such as thoracoscopy and laparoscopy, may allow accurate staging without esophagectomy. Surgical resection provides excellent palliation; however, the chance for cure with esophagectomy alone is only 10% to 20%. Adjuvant treatment with pre- or postesophagectomy radiation may improve local-regional control but does not improve survival. Nor has preoperative chemotherapy been shown to improve survival; however, it remains an active area of investigation. Multimodality therapy, namely, chemotherapy and radiation (chemoradiation), given concurrently prior to surgical resection shows promise, with one study indicating a 5-year survival of 34%. A complete pathologic response to chemoradiation correlates with improved survival. Chemoradiation has been shown to be superior to radiation as primary management of esophageal cancer. There has been no successfully completed randomized trial of surgery versus definitive radiation or chemoradiation. However, chemoradiation represents a reasonable alternative to esophagectomy in the primary management of squamous cell carcinoma of the esophagus and chemoradiation also appears to be effective in the treatment of patients with adenocarcinoma of the esophagus, offering significant palliation and a chance for long-term survival as well. Randomized studies of preoperative chemoradiation versus surgery or versus chemoradiation alone are needed. The treatment of advanced esophageal cancer must be directed toward palliation of symptoms. Newer endoscopic techniques, including the use of expansile metal stents, laser ablation, intraluminal high-dose rate brachytherapy, BICAP tumor probe, or photodynamic therapy, offer selected patients short-term palliation.(ABSTRACT TRUNCATED AT 400 WORDS)