Treatment of carcinoma of the esophagus or cardia

For Gastroesophageal Junction Cancers, Does an "Esophageal" or "Gastric" Surgical Approach Offer Better Perioperative and Oncologic Outcomes?

BACKGROUND

The optimal surgical approach to the resection of gastoesophageal junction cancer is unknown. A comprehensive literature search was conducted to further compare the esophageal and gastric approaches to gastroesophageal junction cancer.

METHODS

A systematic review of the literature from January 1990 to May 2018 was performed to determine whether an esophageal or gastric surgical approach offers better perioperative and oncologic outcomes.

RESULTS

A total of 179 abstracts were identified and after excluding publications for non-English language, primary focus on neoadjuvant and/or adjuvant treatment, lack of comparison of surgical approaches or not addressing morbidity, mortality, or survival-related outcomes, a total of 14 nonrandomized, comparative studies were reviewed in detail.

CONCLUSIONS

The proximal and distant extent of the tumor based on Siewert type classification greatly influences choice of operation. Overall survival rates and surgical outcomes are comparable, and surgical approach should be dictated by patient factors.

Transthoracic resection versus non-transthoracic resection for gastroesophageal junction cancer: a meta-analysis

BACKGROUND

The aim of this meta-analysis is to evaluate the impact of transthoracic resection on long-term survival of patients with GEJ cancer and to compare the postoperative morbidity and mortality of patients undergoing transthoracic resection with those of patients who were not undergoing transthoracic resection.

METHOD

Searches of electronic databases identifying studies from Medline, Cochrane Library trials register, and WHO Trial Registration etc were performed. Outcome measures were survival, postoperative morbidity and mortality, and operation related events.

RESULTS

Twelve studies (including 5 RCTs and 7 non-RCTs) comprising 1105 patients were included in this meta-analysis, with 591 patients assigned treatment with transthoracic resection. Transthoracic resection did not increase the 5-y overall survival rate for RCTs and non-RCTs (HR = 1.01, 95% CI 0.80- 1.29 and HR = 0.89, 95% CI 0.70- 1.14, respectively). Stratified by the Siewert classification, our result showed no obvious differences were observed between the group with transthoracic resection and group without transthoracic resection (P>0.05). The postoperative morbidity (RR = 0.69, 95% CI 0.48- 1.00 and OR = 0.55, 95% CI 0.25- 1.22) and mortality (RD = -0.03, 95% CI -0.06- 0.00 and RD = 0.00, 95% CI -0.05- 0.05) of RCTs and non-RCTs did not suggest any significant differences between the two groups. Hospital stay was long with thransthoracic resection (WMD = -5.80, 95% CI -10.38- -1.23) but did not seem to differ in number of harvested lymph nodes, operation time, blood loss, numbers of patients needing transfusion, and reoperation rate. The results of sensitivity analyses were similar to the primary analyses.

CONCLUSIONS

There were no significant differences of survival rate and postoperative morbidity and mortality between transthoracic resection group and non-transthoracic resection group. Both surgical approaches are acceptable, and that one offers no clear advantage over the other. However, the results should be interpreted cautiously since the qualities of included studies were suboptimal.

Centralisation of oesophagogastric cancer services: can specialist units deliver?

INTRODUCTION

Oesophagogastric cancer surgery is increasingly being performed in only centralised units. The aim of the study was to examine surgical outcomes and service delivery within a specialist unit.

PATIENTS AND METHODS

The case notes of all patients undergoing attempted oesophagogastrectomy between January 2000 and May 2003 were identified from a prospective consultant database.

RESULTS

A total of 187 patients (median age, 63 years; range, 29-83 years; M:F ratio, 3.9:1) underwent attempted oesophago-gastrectomy. Of these, 91% were seen within 2 weeks of referral and treatment was instituted after a mean of 31 days (range, 1-109 days). More patients underwent surgery (63%) than neoadjuvant therapy (56%) within 1 month of referral. The main indication for surgery was invasive malignancy in 166 patients (89%). The 30-day mortality was 0.5% (1 death) and in-hospital mortality was 1.1% (2 deaths). The median length of hospital stay was 14 days (range, 7-69 days). Significant postoperative morbidity included: pulmonary complications (36%), cardiovascular complications (16%), wound infection (13%) and clinically significant anastomotic leaks (7%). Of the study group, 28 patients (15%) were admitted to ICU with a median stay of 10 days (range, 1-44 days); this accounted for 0.9% of ICU bed availability. Twelve patients (6.4%) were returned to theatre, most commonly for bleeding. The 1-year survival rates were 78%. During 2002-2003, national waiting list targets for both hernia repair and cholecystectomy were achieved.

CONCLUSIONS

Despite recent increases in workload, high volume specialist units can deliver an efficient and timely service with both good treatment outcomes and minimal impact upon elective surgical waiting lists and ICU provision.

Neoadjuvant chemotherapy for oesophageal cancer: The need for accurate response prediction and evaluation

Primary surgical resection for locally advanced oesophageal cancer is associated with systemic failure and poor survival due to presence of micrometastatic disease at the time of diagnosis. Neoadjuvant chemotherapy prior to surgical resection aims to downstage these locally advanced tumours. A review of reported randomised controlled trials has shown only one sufficiently powered trial with a survival advantage for cisplatin-based chemotherapy. Published meta-analyses of neoadjuvant chemotherapy trials have shown little or no overall survival benefit. A subgroup of patients with biologically favourable tumours who respond to this treatment have been consistently shown to have a survival advantage. These patients need to be differentiated from non-responders preferably at an early stage of this potentially toxic treatment. Current clinical, endoscopic and radiological methods of response evaluation are all unreliable. Response evaluation with 18FDG-PET has been shown to accurately assess the pathological response and also to predict the risk of local recurrence and overall survival. The development of integrated PET/CT imaging may enhance the accuracy of this response evaluation. In the future, molecular markers of response prediction prior to initiation of treatment may allow the development of individualised treatment strategies. New emerging chemotherapeutic agents may prove to be more effective in eradicating micrometastatic disease.

A fístula esôfago-gástrica cervical

OBJETIVO: Analisar a presença de fístula esôfago-gástrica cervical nos pacientes submetidos a esofagectomias por câncer após reconstrução do trânsito digestivo com o estômago nas três vias: pré-esternal, retro-esternal e mediastino posterior. MÉTODO: Em um total de 180 pacientes portadores de carcinoma de células escamosas de esôfago torácico, tratados no Hospital Geral de Nova Iguaçu e no Hospital EMCOR, de agosto de 1968 a março de 2000, foram realizadas 97 esofagectomias e 70 (72,16%) reconstruções do trânsito digestivo. O tratamento considerado foi essencialmente cirúrgico através da esofagectomia transpleural direita e da esofagectomia transhiatal. A anastomose esôfago-gástrica cervical foi realizada inicialmente em parede anterior do estômago e depois em parede posterior. Paralelamente, foram realizados estudos experimentais em cadáveres frescos no IML (Instituto Médico Legal) de Nova Iguaçu, para avaliação das dimensões das paredes gástricas e pesquisa de suas vascularizações. RESULTADOS: A incidência de fístulas ficou reduzida a 7,69%, quando se passou usar a parede posterior do estômago. A reconstrução do trânsito digestivo foi realizada em 52,86% pela via pré-esternal, 10% pela via retro-esternal e 37,14% pelo leito esofágico. As fístulas ocorreram em 20% dos pacientes (14 casos). Na via pré-esternal ocorreram 24,43% (9 casos), na via retro-esternal 42,85% (3 casos), e mediastino posterior 7,69% (2 casos).( X2= 3,39; p= 0,18) A mortalidade operatória foi de 15,71%, sendo a insuficiência respiratória sua maior causa.((X2= 3,29; p= 0,19). A sobrevida em cinco anos foi de 13,5%. CONCLUSÕES: A esofagectomia com anastomose esôfago-gástrica cervical é o nosso método de escolha. Os melhores resultados foram obtidos com a execução da anastomose esôfago-gástrica cervical na parede posterior do estômago, e através do mediastino posterior.

Preoperative prevalence of Barrett's esophagus in esophageal adenocarcinoma: a systematic review

BACKGROUND & AIMS

The public health impact of past screening and surveillance practices on the outcomes of Barrett's related cancers has not previously been quantified. Our purpose was to determine the prior prevalence of Barrett's esophagus in reported cases of incident adenocarcinoma undergoing resection, as an indirect measure of impact.

METHODS

We performed a systematic review of the literature from 1966 to 2000. Studies were included if they reported: (1) the number of consecutive adenocarcinomas resected, and (2) the number of those resected who had a previously known diagnosis of Barrett's. We generated summary estimates using a random effects model.

RESULTS

We identified and reviewed 752 studies. Twelve studies representing a total of 1503 unique cases of resected adenocarcinomas met inclusion criteria. Using a random effects model, the overall percentage of patients undergoing resection who had a prior diagnosis of Barrett's was 4.7% +/- 2.9%.

CONCLUSIONS

The low prior prevalence (approximately 5%) of Barrett's esophagus in this study population provides indirect evidence to suggest that recent efforts to identify patients with Barrett's-whether through endoscopic screening or evaluation of symptomatic patients-have had minimal public health impact on esophageal adenocarcinoma outcomes. The potential benefits of endoscopic surveillance seem to have been limited to only a fraction of those individuals at risk. These data thus provide a clear and compelling rationale for the development of effective screening strategies to identify patients with Barrett's esophagus.

Complete 5-year follow-up of a prospective phase II trial of preoperative chemoradiotherapy for esophageal cancer

BACKGROUND

Conclusive evidence supporting the routine use of multimodality therapy in esophageal cancer is lacking. However, since long-term survival after esophagectomy alone is unusual, clinical trials designed to identify effective therapeutic regimens are essential. We report here the 5-year results of a phase II induction chemoradiotherapy trial.

METHODS

From August 1991 to January 1995, 44 patients with esophageal or gastroesophageal junction carcinoma were treated with a combination of 5-fluorouracil, cisplatin, and interferon-alpha with concurrent external beam radiotherapy.

RESULTS

Forty-one (93%) patients completed chemoradiotherapy, with most toxic events recorded as grade I or II. Curative resection (all gross tumor removed) was achieved in 36 of 37 surgical explorations, with 10 tumors demonstrating complete pathologic response and 23 showing partial pathologic response. Median follow-up for survivors was 75 months (range, 60-100 months). Five-year survival for all patients was 32%, with a median survival of 28 months. Five-year disease-free survival in patients with curative resection was 36% (median, 26 months) and overall survival was 39% (median, 34 months). Five-year survival for patients with curative resection whose disease responded to chemoradiotherapy was 42% (median overall survival, 36 months). Local-regional recurrence alone occurred in 3 patients, distant failure alone in 12 patients, and combined local-regional and distant failure in 2 patients. A Cox proportional hazards model identified both pathologic tumor and nodal stage as independent predictors of disease-free survival. Fourteen patients (32%) were 5-year survivors; 1 of these patients later experienced disease recurrence and died.

CONCLUSIONS

Preoperative chemoradiotherapy can result in a long-term and durable disease-free state. Only large, multi-institutional phase III trials can determine whether combined modality therapy is superior to resection alone.

Endoscopic palliation of malignant dysphagia

Esophageal cancer is the primary cause of malignant dysphagia, a major cause of morbidity and mortality. In patients with esophageal cancer that is unresectable at the time of diagnosis, palliation is the major goal. Surgical treatment as well as radiation and chemoradiation therapy are traditional approaches for such patients. Endoscopic therapy is useful for patients with poor performance status, those in whom other treatments have failed, and those with tracheoesophageal fistulas. In recent years, self-expanding metal stents have become an important new endoscopic treatment modality for palliation of malignant dysphagia in a wide range of patients. Appropriate patient selection is paramount when a mode of palliation for malignant dysphagia is being selected. Although various treatment options exist for palliation of malignant dysphagia, comparative studies among these modalities are needed.

Analysis of the role of adjuvant chemotherapy for invasive carcinoma of the esophagus

The purpose of this report is to analyze the role and optimum integration of chemotherapy for invasive carcinoma of the esophagus in the combined modality setting. The charts of 157 patients with primary invasive nonmetastatic carcinoma of the esophagus treated with curative intent between 1984 and 1998 were reviewed. Various combinations of chemotherapy (C), radiotherapy (R), and surgery (S) were used. Chemotherapy was multiagent (typically 5-fluorouracil [5-FU]/cisplatin/hydroxyurea, 5-FU/cisplatin/leucovorin, or docetaxel/cisplatin) for all but seven patients treated with single agents. The clinical endpoints examined were overall survival (OS) and cause-specific survival (CSS). Multivariate analyses and pairwise comparisons were made for determination of the benefit of chemotherapy. On the multivariate analyses, only American Joint Committee on Cancer stage and chemotherapy were statistically significant determinants of both OS and CSS. Following are the results of the pairwise analyses: 3-year OS: (no C) versus (any C): 16% versus 27% (p = 0.02); (S) versus (C+S): 19% versus 34% (p = 0.35); (R) versus (C+R): 0% versus 13% (p = 0.05); (R + S) versus (C + R + S): 18% versus 33% (p = 0.03). The administration of adjuvant chemotherapy can improve survival in patients with invasive nonmetastatic esophageal carcinoma. This benefit appears to be greater when chemotherapy is given with radiotherapy (with or without surgery) than in the absence of radiotherapy, perhaps because of a radiosensitizing effect not possible when using surgery is the only local control modality.

The role of multimodality therapy for resectable esophageal cancer

BACKGROUND

There is an increasing interest in the role of combined therapy to achieve long-term survival for patients with resectable esophageal neoplasms. Surgery provides excellent palliation with relatively low morbidity and mortality rates, but cure remains elusive.

MATERIAL AND METHODS

From January 1988 to January 1998, a total of 137 patients met eligibility criteria for a combined multimodal therapy, prospective, nonrandomized protocol of induction chemoradiation therapy followed by surgical resection, based on radiological and endoscopic assessment of the extension (all patients were initially considered to be at clinical stages I to III, locoregional). Consequently, patients with high grade Barrett's dysplasia or any squamous carcinoma in situ (stage 0) and those with distant metastatic disease (stage IV) were excluded. Among this group, 48 operable patients with biopsy-proven esophageal cancer finally entered and completed the protocol and are the sample of the present study. Multivariate logistic regression models were used to identify risk factors for death or recurrence. Actuarial survival was calculated since the beginning of the induction protocol by the Kaplan-Meier method, and comparisons between groups were made by the log-rank test.

RESULTS

Mean age was 61.6 (range 45 to 71), and 72.9% were male. The majority of the tumors (70.8%) were located at the lower third/cardia and as many as 18.8% were adenocarcinoma. After a mean of 7.5 weeks (range 5 to 12) after the completion of the induction phase, 68.7% underwent a transthoracic esophagectomy and 31.3% a transhiatal esophagectomy. The in-hospital mortality rate was 10.4% (5 patients). A complete response (no evidence of tumor within the specimen: pT0) was achieved in 25% (12 patients). After a mean follow-up of 20.2 months, mean survival for the entire group was 18.2 months (95% confidence interval 14 to 22). At the end of the study, 25% (12) remained alive. Actuarial survival rates at 12, 23, and 37 months were 56.2%, 36.9%, and 21.9%, respectively.

CONCLUSIONS

Esophageal resection after induction therapy seems to be related to a slightly higher mortality rate compared with historical series, and for this reason, neoadjuvant therapy must be considered still experimental. However, no statistical significant difference in survival is showed in those cases with complete pathological response (pT0). Factors influencing survival are recurrence and age. Surgery alone remains the standard therapy for esophageal cancer.

Neoadjuvant chemoradiation followed by surgery for resectable esophageal cancer

Neoadjuvant chemoradiation (NAC) therapy protocols were developed to improve survival in patients with resectable esophageal cancer. Our experience with two consecutive NAC therapy trials is reviewed. Both studies included patients with localized squamous cell cancer and adenocarcinoma. Patients were treated with cisplatinum 26 mg/m2/day (days 1-5 and 26-30), 5-Fluorouracil (5-FU) 300 mg/m2/day (days 1-30), concurrent radiotherapy (4400 cGy) followed by esophagectomy. In the second trial, adjuvant taxol was added. The first protocol had 50 patients. Two patients died, both before surgery, one from sepsis. There was no residual viable tumor (CR) in 19 (40%) patients. The median survival time was 31 months. The 5-year survival rate of 36% compared favorably with concurrent 5-year survival of 18% for surgery alone. Forty-one patients were enrolled in the second trial. All underwent surgery. There were no treatment or operative deaths. Survival data for this group is maturing. Combined results from both protocols are: treatment mortality of 2.2%, complete response rate of 37%, and a median and 3-year disease-specific survival of 42 months and 54%, respectively. We conclude that NAC followed by surgery improves survival over surgery alone and that CR is predictive of improved survival.

[Concomitant chemoradiotherapy of cancer of the esophagus]

Radiation therapy with concomitant chemotherapy is the standard treatment for non resectable esophageal carcinoma. For patients with operable tumors, surgery is the traditional treatment. However several data have suggested that preoperative chemo- and radiotherapy could improve therapeutic results. At the present time, no randomized trial has demonstrated, except for adenocarcinoma of the cardia, the benefit of preoperative treatment. Other randomized trials are needed to determine the role and the optimal modalities of these treatments. This is a review of the literature data in concomitant chemotherapy and radiation in the management of esophagus.

Management of dysplasia in the columnar-lined esophagus

The management of patients with high-grade dysplasia in Barrett's esophagus is complex and controversial with regard to electing continued endoscopic biopsy surveillance until an early adenocarcinoma is detected or proceeding with partial esophagogastrectomy. Clinical recommendations to patients for either option should be individualized and based on several parameters reflecting patient and clinician factors. Available data on interpretational variation in the diagnosis of dysplasia; limitation of diagnostic errors with the use of a rigorous, systematic endoscopic biopsy protocol; new information on the apparent benign natural history of high-grade dysplasia in some patients; and the morbidity and mortality of esophageal resection all suggest that recommendation for continued endoscopic biopsy surveillance is an appropriate clinical practice in selected patients. Ongoing research investigations on high-grade dysplasia in Barrett's esophagus aim to reduce the potential for diagnostic errors, simplify cancer surveillance, and develop therapeutic interventions that are safer than but as effective as surgery.

Esophagogastrectomy for carcinoma of the esophagus and cardia: a comparison of findings and results after standard resection in three consecutive eight-year intervals with improved staging criteria

OBJECTIVE

A review of findings and results after standard resection for carcinoma of the esophagus and cardia without neoadjuvant therapy was done to provide a basis for comparison with current reports of radical resection and neoadjuvant therapy.

METHODS

A 24-year experience on one surgical service with 454 operations for carcinoma of the esophagus and cardia was reviewed. A comparison of findings and results in three consecutive 8-year intervals was analyzed, and new staging criteria were developed and compared with those currently favored by the American Joint Committee on Cancer.

RESULTS

From January 1, 1970, to January 1, 1994, 454 patients with carcinoma of the esophagus or cardia underwent operation, of whom 408 (90%) had esophagogastrectomy with a 30-day mortality rate of 2.5% and an additional hospital mortality rate of 1.2%. Of the 121 complications (30.7%), 71 (18%) were major and 50 (12.7%) were minor. Cardiovascular complications predominated. The overall 5-year survival was 24.7%, with a 33.7% survival after complete resections in the most recent interval under study. Palliation of dysphagia was achieved in nearly 80% of patients who survived the operation. During the three intervals under review, resectability, mortality, and complication rates remained constant. The percentages of left thoracotomies and transhiatal resections increased, and there was a decrease in thoracoabdominal incisions. The percentages of patients with Barrett's esophagus and stage 0 and I tumors increased. The percentage of complete resections (R0) increased, whereas that for resections with residual microscopic tumor (R1) decreased, and there was no change in the percentage of patients with residual gross tumor after resection (R2). Modified WNM staging criteria are proposed that provide better prognostic stratification of the disease than those currently favored by The American Joint Committee on Cancer.

CONCLUSIONS

Standard esophagogastrectomy is applicable in 90% of patients with operable carcinoma of the esophagus or cardia, with consistently low mortality and morbidity rates and satisfactory palliation of dysphagia. The 5-year survival (24.7% overall) remains suboptimal, but the current figure for complete resections (33.7%) is encouraging. There is a need for revision of the current American Joint Committee on Cancer staging criteria.

Sequential chemotherapy and radiotherapy for squamous cell esophageal carcinoma

A Phase II study of sequential chemotherapy with 5-fluorouracil and cisplatin followed by radiotherapy was initiated to see whether the use of two therapies sequentially could have an effect on response rate. Thirteen patients with advanced squamous cell carcinoma of the esophagus were treated with 1,000 mg/m2/day 5-fluorouracil days 1-5 continuously and 100 mg/m2 cisplatin on day 1. An average of four cycles (range, one to nine) were given every 28 days; 11 patients received more than three cycles. The radiation consisted of 60 Gy over 6-8 weeks. There was only one (8%) complete response (CR) and 11 (85%) partial responses (PRs). Restaging after radiation revealed no conversion of PR to CR. Median survival was 39 weeks (range, 6-208+). Chemotherapy alone or its use sequentially with radiotherapy is inadequate, and newer approaches are needed to to improve survival.

Intrathoracic anastomosis after oesophageal resection for cancer

Cervical anastomosis has been advocated to avoid the pulmonary complications and life-threatening anastomotic disruptions following intrathoracic oesophagogastric anastomosis. This is a retrospective review of 111 oesophageal resections followed by an intrathoracic anastomosis. These resections were performed between September 1993 and August 1994 within a residency training program. The left thoracoabdominal approach was used for distal tumours and the Ivor Lewis technique for more proximal tumours. Squamous cell carcinoma accounted for 72% patients (n = 80), adenocarcinoma for 25% (n = 28), and others for 2.7% patients (n = 3). Of the patients, 69% had pathologic Stage III tumours. Operative mortality rate was 1.8% (two patients). Perioperative complications occurred in 39 patients, including anastomotic leak in 10 patients and myocardial infarction in 2 patients. In the absence of a leak, there were no major pulmonary complications requiring intensive care or ventilatory support. Of those patients with anastomotic disruption, 80% were salvaged by early clinical diagnosis and appropriate treatment. We conclude that transthoracic oesophagectomy with an intrathoracic anastomosis is a safe procedure that can be performed with low mortality and acceptable morbidity.

Pre-operative staging of gastro-oesophageal junction carcinoma: comparison of endoscopic ultrasound and computed tomography

Fifteen patients with carcinoma of the gastro-oesophageal junction were pre-operatively staged with endoscopic ultrasound (EUS) and computed tomography (CT). The accuracy of tumour and nodal staging using both modalities was compared to the final histological staging of the resected specimens. In staging depth of tumour growth, EUS was significantly more accurate (87% of lesions correctly staged) than CT (40% correctly staged). In staging nodal involvement, EUS was again significantly more accurate (73% correctly staged) than CT (33%). Two-thirds of the lesions were traversable with the endoscopic probe, but most of the nontraversed lesions were correctly staged on EUS. In this study, CT has performed poorly as a staging modality for carcinoma at the gastro-oesophageal junction. Other studies have shown CT to be less accurate at this location than at other oesophageal sites. The orientation of the gastro-oesophageal junction, lack of surrounding fat planes, proximity of adjacent organs and patient motion contribute to the poor staging performance of CT at this location. In contrast, EUS has been an accurate staging modality at the gastro-oesophageal junction in this study and compares well with other studies evaluating EUS in the more proximal oesophagus. Endoscopic ultrasound is therefore a necessary modality if accurate pre-operative staging of gastro-oesophageal junction carcinoma is to be achieved.

Oesophageal cancer: outcome of modern surgical management

Many clinicians still associate oesophagectomy for oesophageal carcinoma with low cure rates, poor palliation and prohibitive peri-operative mortality. Surgical advances have rendered such perceptions inaccurate. A prospective study of all patients undergoing surgery for oesophageal cancer in an Australian teaching hospital between 1979 and 1993 has been undertaken. Selection, staging, pre-operative preparation, surgical technique and postoperative care were all carefully controlled. One hundred and thirty-seven patients were explored. Twenty-one were inoperable. One hundred and sixteen underwent resection with intent to cure. Hospital mortality for oesophagectomy was 1.7%. There were no cases of clinical anastomotic leakage. Eighty-nine per cent achieved excellent to good swallowing. The median survival for all cases was 14 months and the 5 year survival was 18%. Median survival for resected cases was 18 months and the 5 year survival was 26%. The long-term survival was related to postoperative stage of the disease but not to tumour type. Oesophagectomy for oesophageal cancer will restore good swallowing in 90% of cases. Operative mortality should be less than 5% and the overall 5 year survival 20-30%. Early tumours can often be cured (ca in situ 100%, stages I and II 50-60%), indicating the benefits of early detection. Poor survival in advanced disease (stage III 15%, stage IV 0%) on a background of low surgical mortality indicate the need for better staging and more effective adjuvant therapies.

Adenocarcinoma of the gastric cardia

One hundred and ninety-five patients operated on for adenocarcinoma of the gastric cardia during the years 1961-90 were analysed and the present data indicate that the more enthusiastic attitude adopted towards resective surgery led to a significant increase in operative explorations performed and in resectability rate, from 50% (44/88) and 35% (28/88) during the years 1961-75 to 84% (90/107) and 56% (60/107) during the years 1976-90, respectively. The difference between radical resections, 54% (15/28) and 67% (34/60), remained non-significant. The overall postoperative mortality and morbidity after resective surgery were 14% and 35% and these rates did not rise with time. The anastomotic leakage rate was 15%. Anastomotic leakage was, in fact, not only the most common postoperative complication but also the most common cause of death. Overall cumulative survivals at 1, 3 and 5 years were 47%, 11% and 5%. Comparison of the cumulative survival rates between the 15-year periods indicated that there were no differences in overall survival or in survival after resective surgery. We regard these results disappointing, because over half of the patients died in 1 year and because the long-term survival remained dismal.

Improved survival with neoadjuvant therapy and resection for adenocarcinoma of the esophagus

OBJECTIVE

This study sought to determine the impact of preoperative chemotherapy and radiation therapy (neoadjuvant therapy) followed by resection in patients with adenocarcinoma of the esophagus.

SUMMARY BACKGROUND DATA

Long-term survival in patients with carcinoma of the esophagus has been poor. An increase in the incidence of adenocarcinoma of the esophagus has been reported recently.

METHODS

Fifty-eight patients with biopsy-proven adenocarcinoma of the esophagus treated at this institution from January 1951 through February 1993 were studied. Since 1989, 24 patients were entered prospectively into a multimodality treatment protocol consisting of preoperative cisplatin, 5-fluorouracil (5-FU), and leucovorin with or without etoposide, and concomitant mediastinal radiation (30 Gy). Patients were re-evaluated and offered resection.

RESULTS

There were no deaths related to neoadjuvant therapy and toxicity was minimal. Before multimodality therapy was used, the operative mortality rate was 19% (3 of 16 patients). With multimodality therapy, there have been no operative deaths (0 of 23 patients). The median survival time in patients treated before multimodality therapy was 8 months and has yet to be reached for those treated with the neoadjuvant regimen (> 26 months, p < 0.0001). The actuarial survival rate at 24 months was 15% before multimodality therapy and 76% with multimodality therapy. No difference in survival was noted in neoadjuvant protocols with or without etoposide (p = 0.827).

CONCLUSIONS

Multimodality therapy with preoperative chemotherapy and radiation therapy followed by resection appears to offer a survival advantage to patients with adenocarcinoma of the esophagus.

Influence of radiologically and cytologically assessed distant metastases on the survival of patients with esophageal and gastroesophageal junction carcinoma. The Rotterdam Esophageal Tumor Study Group

BACKGROUND

Distant metastasis in carcinoma of the esophagus and gastroesophageal junction is associated with a poor survival after resection. To improve the selection of patients for surgical and nonsurgical treatment, this study determined the influence on survival of distant metastases, as assessed on radiologic studies or proven on cytologic studies.

METHODS

During the period 1989-1990, 135 patients were referred to the institution in this study. On ultrasonographic or computed tomographic studies, distant metastases were suspected in 62 patients and were absent in 73 patients. In 33 patients, metastases were proven cytologically; 32 of these patients subsequently were excluded from surgery. Twelve other patients were unfit for surgery because of their general condition. The remaining 91 patients had surgery; 77 patients had transhiatal esophagectomy, and the tumor was unresectable in 14 patients.

RESULTS

The 2-year survival rate for all patients in whom distant metastases were suspected on radiologic studies was 11.2%, and it was 44.3% for patients without metastases on these studies (P < 0.001). For patients with cytologically proven metastases, the 2-year survival rate (3%) was lower than for patients in whom distant metastases were suspected on radiologic studies but not cytologically confirmed (21.1%) (P < 0.001). There was no statistically significant difference in survival between this last group of patients and those without metastases identified by radiologic studies (P = 0.87). After resection, the 2-year survival rate decreased from 53.9% to 0% when distant metastases were present on histopathologic studies of the resected specimen (P = 0.04), and there was no significant difference in survival between patients with distant metastases suspected or absent on preoperative radiologic studies (P = 0.47).

CONCLUSIONS

Surgery should be avoided in patients with cytologically proven distant metastases because the expected survival rate is low and surgery does not seem to be a life-prolonging procedure in these patients; however, patients should not be excluded from surgery on the basis of metastases identified by radiologic studies alone.

Staging of carcinoma of the esophagus and cardia: a comparison of different staging criteria

The third edition [1988] of the Manual for Staging of Cancer of the American Joint Committee on Cancer (AJCC) was developed to permit finer discrimination between stages than was true of the previous edition [1983]. This study was designed to determine whether or not this goal was achieved. Pathologic staging of the specimens removed from 265 patients with carcinoma of the esophagus or cardia undergoing esophagogastrectomy between 1970 and 1988 was performed according to criteria published in the second and third editions and their survival data compared. The new staging criteria of the AJCC provides no better discrimination of stages according to survival than was true of the earlier version, the 5-year survival of stage IIA patients being similar to that of stage I patients (37.5 +/- 6.7% vs. 50.8 +/- 17.7%), and the survival of stage IIB patients being similar to that of stage III patients (16.2 +/- 8.1% vs. 13.6 +/- 3.7%). However, depth of wall penetration and extent of lymph node involvement were reliable independent predictors of survival. We propose a modified version of the Skinner WNM staging plan that provides a modest increase in staging fragmentation.

Oesophagectomy by a transhiatal approach or thoracotomy: a prospective randomized trial

A prospective randomized trial of 67 patients undergoing oesophagectomy by either a transhiatal approach or right-sided thoracotomy was conducted over a 40-month period. In 32 patients the approach was transhiatal and 35 had a thoracotomy; the groups were well matched before operation. There were two hospital deaths in patients having the transhiatal oesophagectomy and three in those undergoing thoracotomy. Blood transfusion, intensive care stay and overall time of hospitalization were not significantly different between the two groups. There was no difference in the postoperative morbidity rate and, in particular, the incidences of pulmonary complications were similar (19 per cent for transhiatal oesophagectomy, 20 per cent for thoracotomy) with anastomotic fistula in 6 and 9 per cent respectively. The median (range) operating time was significantly longer in patients having thoracotomy (6 (3.5-9.5) versus 4 (3-8) h). Long-term survival was unaffected by the type of operation performed or addition of preoperative chemotherapy or radiotherapy. Nodal status was a significant prognostic factor within but not between the two groups. It is concluded that oesophagectomy by a transhiatal route or right thoracotomy are equally effective surgical options for treatment of squamous cell oesophageal cancer.

Tracheal occlusion from an intrathoracic stomach

A patient presented with recurrent respiratory failure following esophagectomy. Systematic evaluation detected a previously unreported process causing this problem. Simple therapeutic measures were effective once the diagnosis was established.