Controversies in the current therapy of carcinoma of the esophagus

Chemoradiotherapy, with adjuvant surgery for local control, confers a durable survival advantage in adenocarcinoma and squamous cell carcinoma of the oesophagus

INTRODUCTION

Oesophageal cancer usually presents with systemic disease, necessitating systemic therapy. Neo-adjuvant chemoradiotherapy improves short-term survival, but its long-term impact is disputed because of limited accrual, treatment-protocol heterogeneity and a short follow-up of randomised trials.

AIMS

Long-term results of two simultaneous randomised controlled trials (RCTs) comparing neo-adjuvant chemo-radiotherapy and surgery (MMT) with surgical monotherapy were examined, and the response of adenocarcinoma (AC) and squamous cell carcinoma (SCC) to identical regimens compared.

METHODS

Between 1990 and 1997, two RCTs were undertaken on 211 patients. Patients with AC (n=113) or SCC (n=98) were separately-randomised to identical protocols of MMT or surgical monotherapy.

RESULTS

211 patients were followed to 206 months; 104 patients were randomised to MMT (58 AC and 46 SCC, respectively) and 107 to surgery. MMT provided a significant survival-advantage over surgical monotherapy for AC (P=0.004), SCC (P=0.01). There was a 54% relative risk-reduction in lymph-node metastasis following MMT, compared with surgery (64% versus 29%, P<0.001). MMT produced a pathologic complete response (pCR) in 25% and 31% of AC and SCC, respectively. Survival advantage accrued to MMT, pCR and node-negative patients: AC pCR versus surgical monotherapy (P=0.001); residual disease following MMT versus surgical monotherapy (P=0.008); SCC pCR versus surgical monotherapy (P=0.033).

CONCLUSIONS

A survival advantage for MMT persisted long-term in AC and was replicated in SCC. MMT produced loco-regional tumour down-staging to extinction in 25-31% of patients, potentially permitting personalised treatment in this cohort that avoids the morbidity and mortality associated with resection. Node-negative patients with residual localised disease following MMT had a survival advantage over node-negative patients following surgery alone, supporting a systemic effect on micro-metastatic disease.

Esofagogastrectomia com linfadenectomia em dois campos no câncer do esôfago torácico

OBJETIVO: Avaliar as indicações, sobrevida e fatores prognósticos da esofagogastrectomia com linfadenectomia em dois campos no câncer do esôfago torácico. MÉTODOS: Foram avaliados 111 pacientes retrospectivamente no período de janeiro de 1990 a dezembro de 2001 sendo 83 homens e 29 mulheres. A idade média dos pacientes foi 55,1 anos (variando entre 35-79). A linfadenectomia em dois campos foi parcial (Standard) em 34 pacientes(30,6%) e ampliada em 77(69,4%). RESULTADOS: A média de linfonodos dissecados foi de 22,6(variando entre 4 e 50). A doença R0 ocorreu em 53 pacientes(47,7%) a doença residual microscópica (R1) em 57 (52,3%) e a doença residual R2 em um paciente(0,9%). A recidiva ocorreu em 32 pacientes (28,8%) sendo em sete (6,3%) cervical, 17 (15,3%) locorregional e 19 (17,1%) sistêmica. A morbidade e mortalidade pós-operatória foram de 31,5% e 9% respectivamente, sem diferença significativa em relação á extensão da linfadenectomia mediastinal. A sobrevida global dos 111 pacientes em cinco anos foi de 48,4%, sem diferença significativa na sobrevida em relação á extensão da linfadenectomia, porém, houve aumento significativo na sobrevida livre de doença a favor dos paciente submetidos a linfadenectomia mediastinal ampliada(p=0,01). A ausência de doença residual (R0), comprometimento linfonodal (pN0) e o número de linfonodos comprometidos inferior a quatro, indicaram bom prognóstico. CONCLUSÃO: A esofagogastrectomia com linfadenectomia em dois campos apresentou um impacto positivo na taxa de sobrevida em cinco anos nos pacientes com câncer do esôfago torácico, particularmente em relação aos pacientes com ECIII. A linfadenectomia mediastinal ampliada aumentou significativamente a sobrevida livre de doença.

Esofagogastrectomia com linfadenectomia em dois campos no câncer do esôfago torácico

OBJETIVO: Avaliar as indicações, sobrevida e fatores prognósticos da esofagogastrectomia com linfadenectomia em dois campos no câncer do esôfago torácico. MÉTODOS: Foram avaliados 111 pacientes retrospectivamente no período de janeiro de 1990 a dezembro de 2001 sendo 83 homens e 29 mulheres. A idade média dos pacientes foi 55,1 anos (variando entre 35-79). A linfadenectomia em dois campos foi parcial (Standard) em 34 pacientes(30,6%) e ampliada em 77(69,4%). RESULTADOS: A média de linfonodos dissecados foi de 22,6(variando entre 4 e 50). A doença R0 ocorreu em 53 pacientes(47,7%) a doença residual microscópica (R1) em 57 (52,3%) e a doença residual R2 em um paciente(0,9%). A recidiva ocorreu em 32 pacientes (28,8%) sendo em sete (6,3%) cervical, 17 (15,3%) locorregional e 19 (17,1%) sistêmica. A morbidade e mortalidade pós-operatória foram de 31,5% e 9% respectivamente, sem diferença significativa em relação á extensão da linfadenectomia mediastinal. A sobrevida global dos 111 pacientes em cinco anos foi de 48,4%, sem diferença significativa na sobrevida em relação á extensão da linfadenectomia, porém, houve aumento significativo na sobrevida livre de doença a favor dos paciente submetidos a linfadenectomia mediastinal ampliada(p=0,01). A ausência de doença residual (R0), comprometimento linfonodal (pN0) e o número de linfonodos comprometidos inferior a quatro, indicaram bom prognóstico. CONCLUSÃO: A esofagogastrectomia com linfadenectomia em dois campos apresentou um impacto positivo na taxa de sobrevida em cinco anos nos pacientes com câncer do esôfago torácico, particularmente em relação aos pacientes com ECIII. A linfadenectomia mediastinal ampliada aumentou significativamente a sobrevida livre de doença.

The effects of vasopressors on perfusion of gastric graft after esophagectomy. An experimental study

AIMS

To evaluate the impact of the perioperative administration of norepinephrine on the perfusion of the esophageal graft.

METHODS

This is an experimental study. Six swine underwent transhiatal esophagectomy; the stomach was used to replace the resected esophagus. We provoked hemorrhagic shock to the animals and then we administered noradrenaline to restore the blood pressure. We monitored the graft perfusion perioperatively using the technique of microdialysis.

RESULTS

In all animals, the graft experienced severe hypoperfusion after the administration of noradrenaline that was statistically significant.

CONCLUSIONS

Our data support the hypothesis that norepinephrine should be used with extreme caution in the perioperative setting after esophagectomy. Further studies, however, will be required to evaluate the clinical significance of this finding.

Neoadjuvant chemoradiotherapy for esophageal carcinoma: a meta-analysis

BACKGROUND

The effectiveness in improving survival of neoadjuvant chemoradiotherapy (NCRT) in patients undergoing surgery for esophageal carcinoma remains unclear.

METHODS

MEDLINE, the Cochrane Database of Systematic Reviews, BIOSIS Previews, and other resources were searched from January 1966 through January 2003. Randomized trials were selected on the basis of study design (NCRT followed by surgery vs surgery alone). Of 21 potential studies identified by abstract review, 6 (29%) met the inclusion criteria.

RESULTS

Across 6 studies, a total of 374 patients underwent NCRT followed by surgery and 364 underwent surgery alone. In 5 of the 6 studies in our meta-analysis, there was a small, non-statistically significant trend toward improved survival with NCRT. Only 1 study demonstrated a statistically significant benefit to NCRT. In our summary measure for all 6 studies, we found a small, non-statistically significant trend toward improved long-term survival in the NCRT followed by surgery group (relative risk of death in the NCRT group [RR], 0.86; 95% confidence interval [CI], 0.74 to 1.01; P = .07).

CONCLUSIONS

NCRT followed by surgery is associated with a small, non-statistically significant improvement in overall survival. Whether this benefit is sufficient to warrant the considerable expense and risks associated with NCRT should be the subject of future larger randomized trials.

Esophageal cancer: outcomes of surgery, neoadjuvant chemotherapy, and three-dimension conformal radiotherapy

Neoadjuvant chemotherapy and radiation are being utilized with increasing frequency in the multimodal treatment of esophageal cancer, although their effects on morbidity, mortality, and survival remain unclear. The objective of this study was to determine the outcome of multimodal treatment in patients with localized esophageal cancer treated at a single institution. Between 1995 and 2002, 118 patients underwent treatment for localized esophageal cancer, utilizing surgery alone, chemoradiation alone, or surgery following neoadjuvant chemoradiation. There was no statistically significant difference in morbidity, mortality, or length of stay between the patients who received multimodal therapy when compared to surgery alone. A surgical resection after down-staging was possible in 9 out of 28 patients (32%) with a clinically non-resectable tumor (T4 or M1a). Forty-seven percent of the patients who received neoadjuvant therapy had a complete pathologic response with a 3-year survival of 59% as compared to only 20 months in those patients who did not achieve a complete response (P = 0.037). Neoadjuvant chemotherapy administered concomitantly with conformal radiotherapy can be performed safely in the treatment of esophageal cancer, without increasing the operative morbidity, mortality, or length of stay. The higher complete response rates to neoadjuvant treatment (as compared to other reports) may be due to the use of three-dimensional conformal radiation therapy or the novel use of weekly carboplatin and paclitaxel.

Quality of life after esophagectomy

Esophagectomy is associated with high complication rates and consequent mortality. The 5-year survival for esophageal cancer is also discouraging with rates of 6 to 33% after surgery. Nonsurgical series of selected patients have shown similar survival. Therefore, quality of life may be a better assessment of patient outcomes than survival. At present few reports have address quality of life in patients after esophagectomy, particularly in those patients who succumb quickly to recurrent cancer. This article investigates the determinants of quality of life after esophagectomy and reviews the use of quality of life measures in comparative trials. Quality of life measures may become valuable tools in the selection of patients for esophagectomy.

Surgical treatment of oesophageal cancer

Various reconstructive conduits and routes of reconstruction have an impact on operative morbidity and foregut function in patients undergoing oesophagectomy. Advantages of a fundus rotation gastroplasty are the better blood supply and the greater length of the gastric tube and its possible impact on anastomotic complications. For a subgroup of patients with oesophageal carcinoma limited to the lamina propria vagal-sparing oesophagectomy seems to be a good alternative in terms of quality of life to preserve gastric secretory, motor, and reservoir function. Posterior mediastinal reconstruction is usually preferred when complete resection (R0) has been accomplished. Anterior mediastinal reconstruction may secondary prevent dysphagia after incomplete resections due to tumour recurrence (R0, R1). However, for all presently available surgical approaches in the treatment of oesophageal cancer qualified studies (prospective randomised) are needed. In addition, randomized trials are needed to identify the specific subgroups of patients who benefit from neoadjuvant or adjuvant radiochemotherapy.