Skip to main content

Advertisement

SpringerLink
Log in

Advanced esophageal carcinoma

  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

From 1976 until 1990 a total of 212 patients with squamous cell carcinoma of the thoracic esophagus were referred for surgical treatment. Resectability was 84.1% (161 of 191). Actuarial 5-year survival in patients with negative lymph nodes was 51.2% versus 12.4% in lymph nodepositive patients. Therefore advanced carcinoma was defined to compromise all patients with involved regional (N1) or distal lymph nodes (M+Ly) as well as patients with T4 tumors or solid organ metastasis (M+org) irrespective of their lymph node status. Comparing complete (R0) versus incomplete (R1–R2) resections for stage III and IV carcinoma revealed 20% and 0% five-year survivals, respectively. There was no 5-year survival in the stage IV group. When excluding solid organ metastasis, the median survival shifted from 8.5 months after incomplete (R1–R2) to 20 months after complete (R0) resection. In 1991 three-field lymphadenectomy was initiated that included bilateral cervical lymphadenectomy. Thirty-seven patients have been treated so far (23 squamous cell carcinoma, 14 adenocarcinomas). Cervical lymph nodes were positive in 24.3% with an incidence up to 28.5% for distal-third carcinoma. Subsequently, 6 patients (16%) moved from M0 to M+Ly status. Our results confirm the key role of surgery not only in improving survival and locoregional tumor control but in refining the accuracy of staging advanced carcinomas provided complete resection is possible. Nowadays other options in the treatment of advanced carcinoma are mainly based on neoadjuvant chemoradiotherapy with response rates ranging from 40% to 60% but until now without evidence of improved 5-year survival rates and with local or distant failure rates of approximately 30% and 45%, respectively. For clinically nonresectable (T4) or presumed nonresectable tumors, neoadjuvant therapy seems to have an important role, as it may convert these tumors into resectable and therefore potentially curable cancers. Toxicity remains a drawback, as it is probably responsible for preoperative dropouts and slight but definitive higher postoperative mortality and morbidity. When the disease clearly is incurable, the best options today are laser therapy and an endoprosthesis, which result in good relief of dysphagia in approximately 80% to 85% of patients and a procedure-related mortality below 5%.

Résumé

Entre 1976 et 1990, 212 patients ayant un cancer épidermoïde de l'oesophage thoracique ont été traités dans notre unité. La résecabilité a été de 84.1% (161/191). La survie actuarielle à 5 ans a été de 51.2% lorsqu'il n'y avait pas d'atteinte ganglionnaire lymphatique comparée à 12.4% lorsque ces ganglionnaires étaient indemnes. Nous avons défini le cancer avancé comme les cnacers associés à une atteinte ganglionnaire régionale (N1) et/ou distale (M+Ly), ainsí que les tumeurs T4 ou associées à une métastase d'un organe solide (M+org), quel que soit l'état des ganglions. La survie a été de 20% et de 0%, respectivement, lorsqu'on a comparé la résection complète (R0) à la résection incomplète (R1–R2) chez les patients ayant un cancer stades III et IV. Il n'y a pas eu de survivant à 5 ans chez les patients stade IV. Lorsqu'on exclut les patients ayant une métastase siegeant au niveau d'un organe plein, la survie médiane passe de 8.5 mois pour les patients ayant eu une résection incomplète (R1–R2) à 20 mois après une résection complète (R0).

Depuis 1991, nous pratiquons une lymphadénectomie à trois champs en plus d'un curage cervical. Trente-sept patients ont été traités ainsi (23 cancers épidermoïdes, 14 adénocarcinomes). La lymphadénectomie cervicale a été positive chez 24.3% des cas en moyenne, 28.5% des cas lorsque le cancer intéressait le tiers supérieur de l'oesophage. Par la suite, six patients, (16%) ont du changer de catégorie, passant de M0 à M+Ly.

Nos résultats confirment le rôle essentiel de la chirurgie, qui, non seulement, améliore la survie et le contrôle locorégional mais aussi permet une classification anatomique précise des lesions dans le cancer avancé, à condition bien entendu que la résection complète soit possible.

Actuellement, les autres moyens thérapeutiques à notre disposition sont la chimio (radio-) thérapie dont les réponses varient entre 40 à 60%, mais, jusqu'à présent, sans preuve que celà améliore la survie à 5 ans. Les récidives locales et régionales sont d'environ 30 et 45%, respectivement. Dans les cas de tumeurs cliniquement non résecables (T4) ou présumées telles, la thérapie néoadjuvante semble importante et capable de rendre un certain nombre de ces tumeurs résecables, c'est-à-dire, potentiellement curables par résection. La toxicité est par contre un inconvénient majeur, responsable de l'abandon préopératoire de traitement et d'une certaine augmentation de la morbidité et de la mortalité postopératoires.

Lorsque la maladie est manifestement incurable, la meilleur option apparaît le forage par laser ou la mise en place d'une endoprothèse ce qui améliore la dysphagie chez 80–85% des cas avec une mortalité inférieure à 5%.

Resumen

Entre 1976 y 1990, doscientos doce pacientes con carcinoma escamocelular del esófago torácico fueron referidos a nuestro servicio para tratamiento quirúrgico. La tasa de resectabilidad fue 84.1% (161/19); la de sobrevida actuarial en los pacientes con ganglios linfáticos negativos fue de 51.2% vs. 12.4% en los casos con ganglios positivos. Por consiguiente, se consideró como casos de carcinoma avanzado a aquellos pacientes con ganglios afectados regionales (N1) y los distales (M+Ly), así como a los pacientes con tumores T4 o con metástasis a órganos sólidos (M+org), independiente de su status ganglionar. La comparación entre los pacientes en que se hizo resección completa (R0) vs. incompleta (R1–R2) para carcinomas en estados III y IV reveló una sobrevida a cinco años de 20% y de 0, respectivamente. No hubo sobrevida a 5 años entre los pacientes con estado IV. Al excluir los casos con metástasis a órganos sólidos la sobrevida media varió desde 8.5 meses en los casos de resección incompleta (R1–R2) a 20 meses en los de resección completa (R0).

A partir de 1991 se inició la linfadenectomía de tres campos, la cual incluye linfadenectomía cervical bilateral; 37 pacientes han sido tratados, 23 con carcinoma escamocelular y 14 con adenocarcinoma. Los ganglios cervicales fueron positivos en 24.3%, con una incidencia de carcinoma del tercio distal hasta de 28.5%. Luego de la operación, seis pacientes (16%) fueron reclasificados del estadío M0 al M0+Ly.

Nuestros resultados confirman el papel clave de la cirugía no solo en cuanto en mejorar los resultados de sobrevida y el control local-regional sino también a redefinir la certeza de la estadificación de los carcinomas avanzados, siempre y cuando sea posible realizar la resección completa.

Actualmente las otras opciones en el manejo del carcinoma avanzado se fundamentan principalmente en la quimio (radio) terapia neoadyuvante con tasas de respuesta que oscilan entre 40% y 60% pero, hasta ahora, sin evidencia de mejoría de la sobrevida a cinco años y con fallas locales y a distancia de aproximadamente 30% a 45%. Sin embargo, en los pacientes con tumores clínicamente no resecables (T4), o presumiblemente no resecables, la terapia neoadyuvante parece adquirir un papel más importante al lograr convertir estos tumores a casos resecables y, por consiguiente, potencialmente curables. La toxicidad sigue siendo un factor limitante y posiblemente responsable del número de casos que no completan el régimen preoperatorio así como de las ligeras, pero definitivamente más altas tasas, de morbilidad y mortalidad postoperatorias.

Cuando la enfermedad aparece claramente incurable, las mejores opciones en la actualidad son la resección endoscópica con láser o la endoprótesis, que resultan en buena paliación de la disfagia en aproximadamente 80–85% de los pacientes con una mortalidad relativa al procedimiento de menos de 5%.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Muller, J.M., Erasmi, H., Stelzner, M.: Surgical therapy of oesophageal carcinoma. Br. J. Surg. 77:845, 1990

    Google Scholar 

  2. Earlam, R., Cunha-Melo, J.R.: Oesophageal squamous cell carcinoma: a critical review of surgery. Br. J. Surg. 67:382, 1980

    Google Scholar 

  3. Akiyama, H., Tsurumaru, M., Kawanura, T., Ono, Y.: Principles of surgical treatment for carcinoma of the esophagus: analysis of lymph node involvement. Ann. Surg. 194:435, 1981

    Google Scholar 

  4. Hermaneck, P., Sobin, L.H., editors: International Union Against Cancer (UICC) TNM Classification of Malignant Tumors (4th ed.). Berlin, Springer, 1987

    Google Scholar 

  5. Altorki, N.K., Skinner, D.B.: En bloc oesophagectomy: the first 100 patients. Hepatogastroenterology 37:360, 1990

    Google Scholar 

  6. Orringer, M.B., Marshall, B., Stirling, M.C.: Transhiatal esophagectomy for benign and malignant disease. J. Thorac. Cardiovasc. Surg. 105:265, 1993

    Google Scholar 

  7. Kelsen, D.P.: Preoperative chemotherapy in esophageal carcinoma. World J. Surg. 11:433, 1987

    Google Scholar 

  8. Leichman, L., Steiger, Z., Seydel, L.: Combined preoperative chemotherapy and irradiation for cancer of esophagus. J. Clin. Oncol. 2:75, 1984

    Google Scholar 

  9. SAS Supplementary Library User's Guide, Version 5. Cary, NC, SAS Institute, 1986

  10. Pearson, J.G.: Radiotherapy of carcinoma of the oesophagus and postcricoid region in South East Scotland. Clin. Radiol. 17:242, 1966

    Google Scholar 

  11. Earlam, R., Cunha-Melo, J.R.: Oesophageal squamous cell carcinoma: a critical review of radiotherapy. Br. J. Surg. 67:451, 1980

    Google Scholar 

  12. Earlam, R.J., Johnson, L.: 101 oesophageal cancers; a surgeon uses radiotherapy. Ann. R. Coll. Surg. Engl. 72:32, 1990

    Google Scholar 

  13. Harrison, L.B., Fogel, T.D., Picone, J.R., Fischer, D.B., Weissberg, J.B.: Radiation therapy for squamous cell carcinoma of the esophagus. J. Surg. Oncol. 37:40, 1988

    Google Scholar 

  14. Rowland, C.G., Pagliero, K.M.: Intracavitary irradiation in palliation of carcinoma of the oesophagus. Lancet 1:1981, 1985

    Google Scholar 

  15. Flores, A.D., Stoller, J.L., Nelems, B., Hay, J, Jackson, S.M.: Combined primary treatment of cancer of the oesophagus and cardia by intracavitary irradiation. In Diseases of the Oesophagus, J.R. Siewert, Holscher, editors. Berlin, Springer, 1987, pp. 741–749

    Google Scholar 

  16. Sur, R.K., Sing, D.P., Sharma, S.C., et al.: Radiation therapy of esophageal cancer: role of high dose rate brachytherapy. Int. J. Radiat. Oncol. Biol. Phys. 22:1043, 1992

    Google Scholar 

  17. Welvaart, K., Caspers, R., Verkes, R., Hermans, J.: The choice between surgical resection and radiation therapy for patients with cancer of the esophagus and cardia: a retrospective comparison between two treatments. J. Surg. Oncol. 47:225, 1991

    Google Scholar 

  18. Caspers, R.J.L., Zwinderman, A.H. Griffioen, G., Welvaart, K., Leer, J.W.H.: Combinatie van uit-en inwendige radiotherapie voor het oesofaguscarcinoom: een nieuw perspectief. Ned. Tijdschr. Geneeskd. 137:465, 1993

    Google Scholar 

  19. Gignoux, M., Roussel, A., Paillot, B., Gillet, M.: The value of praeoperative radio-therapy in esophageal cancer: results of a study of the EORTC. World J. Surg. 11:426, 1987

    Google Scholar 

  20. Launois, B., Delarue, D., Campion, J.P., Kerbaol, M.: Preoperative radiotherapy for carcinoma of the esophagus. Surg. Gynecol. Obstet. 153:69, 1981

    Google Scholar 

  21. Ténière, P., Hay, J.M., Fingerhut, A., Fagniez, P.L.: Postoperative radiation therapy does not increase survival after curative resection for squamous cell carcinoma of the middle and lower esophagus as shown by a multicenter controlled trial. Surg. Gynecol. Obstet. 173:123, 1991

    Google Scholar 

  22. Forastiere, A.A., Orringer, M.B., Porez-Tamayo, C., Urban, S.G., Zahurak, M.: Preoperative chemoradiation followed by transhiatal esophagectomy for carcinoma of the esophagus: final report. J. Clin. Oncol. 11:1118, 1993

    Google Scholar 

  23. Wolfe, W., Vaughn, A.L., Seigler, H.F., et al.: Survival of patients with carcinoma of the esophagus treated with combined-modality therapy. J. Thorac. Cardiovasc. Surg. 105:749, 1993

    Google Scholar 

  24. Kavanagh, B., Anscher, M., Leopold, K., et al.: Patterns of failure following combined modality therapy for esophageal cancer, 1984–1990. Int. J. Radiat. Oncol. Biol. Phys. 24:633, 1992

    Google Scholar 

  25. Le Prise, E., Ben Hassel, M., Gedouin, D., Launois, B.: A 5FU-cisplatinum-radiation therapy combination in the treatment of squamous cell carcinoma of the oesophagus: a phase II study. Gullet 2:24, 1992

    Google Scholar 

  26. Nishihira, T., Hirayama, K., Shineha, R., Akaishi, T., Mori, S.: Aggressive adjuvant therapy prolongs survival of patients with metastatic carcinoma of the thoracic esophagus. Dis. Esophagus 3:29, 1990

    Google Scholar 

  27. Gisselbrecht, C., Gayet, B., Maylin, C., Fekete, F.F.: Chemotherapy-radiotherapy versus control group in advanced esophageal carcinoma [abstract]. Proc. Am. Soc. Clin. Oncol. 5:86, 1986

    Google Scholar 

  28. Wara, W.M., Mauch, P.M., Thomas, A.N., Philips, T.L.: Palliation for carcinoma of the esophagus. Radiology 121:717, 1976

    Google Scholar 

  29. Newaishy, G.A., Read, G.A., Duncan, W., Kerr, G.R.: Results of radical radiotherapy of squamous cell carcinoma of the oesophagus. Clin. Radiol. 33:347, 1982

    Google Scholar 

  30. De Leyn, P., Coosemans, W., Lerut, T.: Early and late functional results in patients after oesophagectomy for carcinoma. Eur. J. Cardiothorac. Surg. 6:79, 1992

    Google Scholar 

  31. Hishikawa, Y., Tanaka, S., Miura, T.: Esophageal ulceration induced by intracavitary irradiation for esophageal carcinoma. A.J.R. 143:269, 1984

    Google Scholar 

  32. Astrahan, M.A., Sapozink, M.D., Luxton, G., Kampp, T.D., Petrovich, Z.: A technique for combining microwave hyperthermia with intraluminal brachytherapy of the oesophagus. Int. J. Hyperthermia 5:37, 1989

    Google Scholar 

  33. Poplin, E., Fleming, T., Leichman, L.: Combined therapies for squamous cell carcinoma of the esophagus, a Southwest Oncology Group study (SWOG 8037). J. Clin. Oncol. 5:622, 1987

    Google Scholar 

  34. Schlag, P.M.: Randomized trial of preoperative chemotherapy for squamous cell cancer of the esophagus. Arch. Surg. 127:1446, 1992

    Google Scholar 

  35. Taylor, S., Bonom, P., Kiel, K.: Failure of simultaneous cisplatin-5-FU infusion chemotherapy and radiation to improve control of oesophageal cancer. Proc. Am. Soc. Clin. Oncol. 5:88, 1986

    Google Scholar 

  36. Segalin, A., Little, A.G., Ruol, A., et al.: Surgical and endoscopic palliation of esophageal carcinoma. Ann. Thorac. Surg. 48:267, 1989

    Google Scholar 

  37. Gasparri, G., Casalegno, P.A., Camandona, M.: Endoscopic insertion of 248 protheses in inoperable carcinoma of the esophagus and cardia: short and long-term results. Gastrointest. Endosc. 33:354, 1987

    Google Scholar 

  38. Carter, R., Smith, J.S., Anderson, J.R.: Laser recanalization versus endoscopic intubation in the palliation of malignant dysphagia: a randomized prospective study. Br. J. Surg. 79:1167, 1992

    Google Scholar 

  39. Shmueli, E., Myszor, M.F., Burke, D., Record, C.O., Matthewson, K.: Limitations of laser treatment for malignant dysphagia. Br. J. Surg. 79:778, 1992

    Google Scholar 

  40. Fleischer, D.: Endoscopic laser therapy for oesophageal cancer: present status with emphasis on past and future. Laser Surg. Med. 9:6, 1989

    Google Scholar 

  41. Rutgeerts, P., Vantrappen, G., Broeckaert, L.: Palliative Nd-YAG laser therapy for cancer of the esophagus and gastro-oesophageal junction: impact on the quality of the remaining life. Gastrointest. Endosc. 34:87, 1988

    Google Scholar 

  42. Lundell, L., Leth, R., Lind, T., Lohnroth, H., Sjovall, M., Olbe, L.: Palliative endoscopic dilatation in carcinoma of the esophagus and esophagogastric junction. Acta Chir. Scand. 155:179, 1989

    Google Scholar 

  43. Payne-James, J.J., Spiller, R.C., Misiewicz, J.J., Silk, D.B.A.: Use of ethanol induced tumor necrosis to palliate dysphagia in patients with esophagogastric cancer. Gastrointest. Endosc. 36:43, 1990

    Google Scholar 

  44. Johnston, J.H., Fleisheer, D., Petrini, J., Nord, J.: Palliative bipolar electrocoagulation therapy of obstruction esophageal cancer. Gastrointest. Endosc. 33:349, 1987

    Google Scholar 

  45. Manyak, M.J., Russo, A., Smith, P.D., Glatstein, E.: Photodynamic therapy. J. Clin. Oncol. 6:380, 1988

    Google Scholar 

  46. Ide, H., Hanyu, F., Murata, Y., Kobayashi, A., Yamada, A., Kobayashi, S.: Extended dissection for thoracic esophageal cancer based on preoperative staging. In Diseases of the Esophagus. Vol. I. Malignant Diseases, M.K. Ferguson, A.G. Little, D.B. Skinner, editors. Mount Kisco, NY, Futura, 1980, pp. 177–186

    Google Scholar 

  47. Tio, T.L.C., Coene, P.L.O., den Hartog Jagen, F.C.A., Tytgat, G.N.J.: Preoparative TNM classification of esophageal carcinoma by endosonography. Hepatogastroenterology 37:376, 1990

    Google Scholar 

  48. Siewert, J.R., Roder, J.D.: Lymphadenectomy in esophageal cancer surgery. Dis. Esophagus 5:91, 1992

    Google Scholar 

  49. Peracchia, A., Ruol, A., Bardini, A., Segalin, C., Castoro, C., Asolati, M.: Lymph node dissection for cancer of the thoracic esophagus: how extended should it be? Analysis of personal data and review of the literature. Dis. Esophagus 5:69, 1992

    Google Scholar 

  50. Desai, P.B., Deshpande, R.K., Patil, P.K., Mistry, R.C.: Radical lymphadenectomy in esophageal cancer: does it improve survival? Dis. Esophagus 5:99, 1992

    Google Scholar 

  51. Lerut, T., De Leyn, P., Coosemans, W., Van Raemdonck, D., Scheys, I., Lesaffre, E.: Surgical strategies in esophageal carcinoma with emphasis on radical lymphadenctomy. Ann. Surg. 216:583, 1992

    Google Scholar 

  52. Kato, H., Watanabe, H., Tachimori, R., Iizuka, T.: Evaluation of neck lymph node dissection of thoracic esphageal carcinoma. Ann. Thorac. Surg. 51:931, 1992

    Google Scholar 

  53. Isono, K., Sato, H., Nakyama, K.: Results of a nationwide study on three field lymph node dissection of oesphageal cancer. Oncology 48:411, 1991

    Google Scholar 

  54. Barbier, P.A., Luder, P.J., Scheepfer, G., Becker, C.D., Wasner, H.E.: Quality of life and patterns of recurrence following transhiatal esophagectomy for cancer: a prospective follow-up in 50 patients. World J. Surg. 12:270, 1988

    Google Scholar 

  55. Akiyama, H.: Surgery for advanced cancer of the oesophagus. In Surgery for Cancer of the Oesophagus, H. Akyama, editor. Baltimore, Williams & Wilkins, 1990, pp. 90–99

    Google Scholar 

  56. Mannell, A., Becker, P.J., Nissenbaum, M.: Bypass surgery for unresectable oesophageal cancer: early and late results in 124 cases. Br. J. Surg. 75:283, 1988

    Google Scholar 

  57. Peracchia, A., Debesi, P., Castro, D., et al.: Results of surgery after cisplatin and 5-FU combination chemotherapy for locally advanced esophageal squamous cell carcinoma. In Diseases of the Esophagus. Vol. I. Malignant Diseases, M. Furguson, A.G. Little, D.B. Skinner, editors. Mount Kisco, NY, Futura, 1990, pp. 299–304

    Google Scholar 

  58. Reed, C.E., Marsh, W.H., Carlson, L.S., Seymore, C.H., Kratz, J.M.: Prospective, randomized trial of palliative treatment for unresectable cancer of the esophagus. Ann. Thorac. Surg. 51:552, 1991

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, Department of General Thoracic Surgery, Catholic University Leuven, U.Z. Gasthuisberg, Herestraat 49, 3000, Leuven, Belgium

    Toni E. Lerut M.D., Ph.D., Paul de Leyn M.D., Willy Coosemans M.D., Dirk Van Raemdonck M.D., Philippe Cuypers & Ben Van Cleynenbreughel

Authors
  1. Toni E. Lerut M.D., Ph.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Paul de Leyn M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Willy Coosemans M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Dirk Van Raemdonck M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Philippe Cuypers
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ben Van Cleynenbreughel
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Lerut, T.E., de Leyn, P., Coosemans, W. et al. Advanced esophageal carcinoma. World J. Surg. 18, 379–387 (1994). https://doi.org/10.1007/BF00316818

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF00316818

Keywords

Search

Navigation