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Current Management of Cervical Esophageal Cancer
Abstract and Figures
Pharyngo-laryngo-esophagectomy (PLE) has been regarded as a standard treatment for cervical esophageal cancer, but the morbidity and mortality rates associated with PLE are substantial. Chemoradiation (CTRT) is widely used to treat esophageal cancer; however, its role in managing cervical esophageal cancer has not been fully elucidated. It was hypothesized that up-front CTRT could be an effective alternative treatment option to PLE. The purpose of this study was to compare the outcomes of patients with cervical esophageal cancer treated with these two methods.
Patients with cervical esophageal cancer from 1995 to 2008 were studied. Three main groups were identified: those treated with PLE, those managed with up-front concurrent chemoradiation, and those not suitable for either PLE or chemoradiation but to whom palliative treatment was offered. The demographics, management strategies, and outcomes of these patients were studied and analyzed.
A total of 107 patients were studied: 87 (81.3%) were men, and the median age was 64 years (range 17-92 years). There were 62 patients who underwent PLE as the primary treatment, 21 had up-front chemoradiation, and the others had palliative treatment. In the PLE group, curative resection was achieved in 37 (59.7%) patients, 20 of whom had either adjuvant chemoradiation or radiotherapy. The hospital mortality rate was 7.1%. In the chemoradiation group, 10 (47.6%) had tumor down-staging, 6 of whom achieved a clinically complete response. Among the 11 patients with poor response, 5 required salvage PLE for palliation. Chemoradiation-associated morbidities included oral mucositis, bilateral vocal cord palsy, esophageal stricture, carotid artery blowout, and permanent hypothyroidism and hypoparathyroidism. The median survival durations of patients in the PLE and chemoradiation groups were 20 and 25 months respectively (P = 0.39).
Up-front chemoradiation can be an alternative therapeutic strategy to PLE. However, this method is not without drawbacks. A significant proportion also requires salvage surgery. Both PLE and chemoradiation have significant curative as well as palliative role in the management of cervical esophageal cancer and treatment should be individualized.
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... In none of non-surgical subgroups analyzed radiation therapy was employed as a single modality. Concurrent CRT for CEC using linear accelerators became a treatment of choice [3,[9][10][11][12][13]. On the other hand, all surgical patients received RT, or chemotherapy, or CRT predominantly as a preoperative procedure [9,[14][15][16]. ...
... Gastro-intestinal integrity restoration requires complex esophagoplasty or/and pharyngoplasty [2,14,17,20], including visceral grafts transposition and autotransplantation [2,14,17,19,21]. R0 resection may fail [10,17,19] whilst R1 procedure should not be regarded as lacking oncology essence [10,17]. Surgery for CEC may be accompanied by postoperative complications. ...
... Gastro-intestinal integrity restoration requires complex esophagoplasty or/and pharyngoplasty [2,14,17,20], including visceral grafts transposition and autotransplantation [2,14,17,19,21]. R0 resection may fail [10,17,19] whilst R1 procedure should not be regarded as lacking oncology essence [10,17]. Surgery for CEC may be accompanied by postoperative complications. ...
Objectives . Up to date managing a cervical esophageal carcinoma (CEC) has remained a controversial challenge. The choice of treatment is still uncertain. In the present review we attempted to assess eligibility of surgery in treatment of CEC. Material and Methods . We have enquired particular publication databases and the enquiries yielded 24 contributions matching study selection criteria such as (1) original articles published from 2000 to 2022, (2) primary tumor localization in the cervical esophagus, (3) squamous cell carcinoma, (4) available characteristics of studied groups (age, sex, T, N, M, stage), (5) detailed description of curative procedures (radiation therapy, chemotherapy, surgery), (6) information about overall survival. These publications represented two arms of 14 surgical and 17 non-surgical subgroups to analyze. Individual patient data and parameter estimates have been renewed on the basis of original Kaplan‒Meier curves plotted. Results . The analysis revealed a highly heterogeneous (I2 =83.76 %; 95 % CI, 71.40–92.16) random effects model. Including a surgical option into treatment of CEC did not affect 3-year overall survival (р=0.665); 46.4 % (95 % CI, 37.4–55.6) vs 43.7 % (95 % CI, 35.3–51.6), respectively. Possibilities of surgical and non-surgical modalities employment were discussed. Conclusion . In treatment of CEC CRT and surgery are non-inferior to each other. These modalities are evenly associated with posterior side effects and complications, which adversely affect functional outcomes and survival. The choice of a treatment mode may depend on tumor response to induction therapy. The latter demands further investigations.
... Given the critical location and extensive involvement of the tumor, total pharyngoesopphagectomy (TPLE) followed by digestive reconstruction have been the most popular treatment modalities in the past (4). Definitive chemoradiotherapy (dCRT) and multimodality therapy (such as neoadjuvant chemoradiotherapy followed by surgery or surgery plus adjuvant chemotherapy) have gradually become central in the therapies of HPCECs (5,6). It is worth noting that salvage TPLE surgery is a recommended choice for residual and recurrent disease when definitive medical treatment fails (7,8). ...
... TPLE surgical resection is a commonly used surgical method for cervical esophageal and hypopharyngeal cancer. However, such surgery has great trauma and high perioperative risk (6), so it is urgent to improve the surgical technique and prove its safety and effectiveness. As an effective surgical tool, stapling device has been widely used in the surgical treatment of esophageal cancer, which can greatly reduce operative time and the incidence of anastomotic fistula (9). ...
... The prognosis for hypopharyngeal and cervical esophageal cancers are poor, mainly because tumors in these areas remain asymptomatic until the diseases reach an advanced stage (15). With the improvement of radiotherapy and chemotherapy technologies, locally advanced HPCECs patients can not only avoid the trauma and perioperative risk caused by surgery, but also obtain the preservation of organ function (6,16). ...
Background
Total pharyngolaryngoesophagectomy (TPLE) is considered as a curative treatment for hypopharynx cancer and cervical esophageal carcinomas (HPCECs). Traditional pharyngo-gastric anastomosis is usually performed manually, and postoperative complications are common. The aim of this study was to introduce a new technique for mechanical anastomosis and to evaluate perioperative outcomes and prognosis.
Methods
From May 1995 to Nov 2021, a series of 75 consecutive patients who received TPLE for a pathological diagnosis of HPCECs at Sun Yat-sen Memorial Hospital were evaluated. Mechanical anastomosis was performed in 28 cases and manual anastomosis was performed in 47 cases. The data from these patients were retrospectively analyzed.
Results
The mean age was 57.6 years, and 20% of the patients were female. The rate of anastomotic fistula and wound infection in the mechanical group were significantly lower than that in the manual group. The operation time, intraoperative blood loss and postoperative hospital stays were significantly higher in the manual group than that in the mechanical group. The R0 resection rate and the tumor characteristics were not significantly different between groups. There was no significant difference in overall survival and disease-free survival between the two groups.
Conclusion
The mechanical anastomosis technology adopted by this study was shown to be a safer and more effective procedure with similar survival comparable to that of manual anastomosis for the HPCECs patients.
... Revision of title and abstract lead to the rejection of 7100 articles, while 72 papers were obtained for full text assessment. According to the abovementioned inclusion and exclusion criteria, 18 articles were included in the qualitative and quantitative synthesis [25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42]. ...
... Furthermore, CEC is a relatively rare disease, and mainly retrospective single-arm studies have been published at this time. Besides, discordant data have been reported, with a 5-year OS for primary surgery ranging from 18 to 54% [25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42]. ...
... On the other hand, if a larynx-preserving procedure is technically feasible, both treatments may be proposed, and the decision should be customized to the single patient. In this setting, there are few studies that directly compare the oncological outcomes of primary surgery and primary CRT, and their retrospective design usually introduce an important selection bias [9,38,39]. Unfortunately, no randomized controlled trials (RCTs) comparing the two treatment modalities have been published at this time. In fact, patients suffering from cancer rarely accept to be randomized between surgical and non-surgical approaches, and the rarity of CEC further limits the design of RCTs. ...
Purpose
To determine the oncological outcomes of cervical esophageal cancer (CEC) treated primarily with surgery.
Methods
A systematic review and meta-analysis was performed according to the PRISMA guidelines.
Results
A total of 868 patients were included from 18 studies. Estimated pooled Overall Survival (OS) rates (95% Confidence Interval, CI) at 1 and 5 years were 74.4% (66.5–83.3), and 26.6% (20.3–34.7), respectively. Larynx non-preserving surgery (n = 229) showed an estimated pooled OS rates (95% CI) at 1 and 5 years of 59.3% (51.5–68.2) and 14.6% (8.8–24.3), respectively. On the other hand, larynx preserving surgery (n = 213) showed an estimated pooled OS rates (95% CI) at 1 and 5 years of 83.6% (78.2–89.4) and 35.1% (24.9–49.6), respectively.
Conclusions
Primary larynx-preserving surgery remains a valuable option for the management of CEC, with similar survival outcomes compared to primary chemoradiotherapy (CRT). On the other hand, larynx non-preserving surgery showed a significantly reduced survival, that may reflect the more advanced T classification of these tumors. Further studies are mandatory to directly compare primary surgery and primary CRT, distinguishing larynx preserving and non-preserving surgery.
... Moreover, most patients treated with surgery must also undergo total laryngectomy, which adversely impacts their quality of life due to loss of the voice. In contrast, definitive chemoradiation therapy (CRT) has shown similar overall outcomes to surgical resection, but without the need for total laryngectomy [6]. Hence, current guidelines recommend definitive CRT as the standard treatment for cervical esophageal http://www.jchestsurg.org ...
... The rate of locoregional recurrence following definitive CRT ranges from 13% to 42% [3], and salvage surgery can be a beneficial option with favorable outcomes, provided the patient's general condition permits [9]. Furthermore, definitive CRT can lead to complications such as esophageal stricture and tumor rupture, necessitating salvage surgery [6]. Hence, the surgical outcomes for cervical esophageal cancer should be reviewed. ...
Background:
Cervical esophageal cancer is a rare malignancy that requires specialized care. While definitive chemoradiation is the standard treatment approach, surgery remains a valuable option for certain patients. This study examined the surgical outcomes of patients with cervical esophageal cancer.
Methods:
The study involved a retrospective review and analysis of 24 patients with cervical esophageal cancer. These patients underwent surgical resection between September 1994 and December 2018.
Results:
The mean age of the patients was 61.0±10.2 years, and 22 (91.7%) of them were male. Furthermore, 21 patients (87.5%) had T3 or T4 tumors, and 11 (45.8%) exhibited lymph node metastasis. Gastric pull-up with esophagectomy was performed for 19 patients (79.2%), while 5 (20.8%) underwent free jejunal graft with cervical esophagectomy. The 30-day operative mortality rate was 8.3%. During the follow-up period, complications included leakage at the anastomotic site in 9 cases (37.5%) and graft necrosis of the gastric conduit in 1 case. Progression to oral feeding was achieved in 20 patients (83.3%). Fifteen patients (62.5%) displayed tumor recurrence. The median time from surgery to recurrence was 10.5 months, and the 1-year recurrence rate was 73.3%. The 1-year and 3-year survival rates were 75% and 33.3%, respectively, with a median survival period of 17 months.
Conclusion:
Patients with cervical esophageal cancer who underwent surgical resection faced unfavorable outcomes and relatively poor survival. The selection of cases and decision to proceed with surgery should be made cautiously, considering the risk of severe complications.
... Previous reports have found similar OS after surgery, radiotherapy (RT), and definitive chemoraidotherapy (CRT) (5,10). RT and CRT gradually became the preferred treatments for UEC in many countries and regions, including the United States (3,11,12). However, among patients with resectable tumors, long-term outcomes were significantly improved for those who underwent surgery compared with those who received only received definitive CRT (13). ...
... In most countries and regions including the US, first-line strategies for UEC are CRT and RT (2,3,11,12). Our study revealed that RT was commonly used. ...
Background
Upper esophageal cancer (UEC) is rare in both Eastern and Western countries. The epidemiological characteristics and long-term survival of UEC patients are less known. In addition, the choice of optimal treatment for UEC has been controversial.
Methods
Cases of UEC (C15.3 and C15.0) arising during the period from 1973 to 2013 were identified and selected using the SEER database. Student's t -test and Pearson's chi-square test were used to compare the differences in parameters among different groups. Esophageal cancer-specific survival (ECSS) and overall survival (OS) rates were calculated by using the Kaplan–Meier method. Cox proportional hazard regression was used to analyze predictive factors.
Results
In the past 40 years, the cases of UEC have gradually increased, and the proportion of adenocarcinoma (AD) has gradually increased (from 3.6% to 11.8%, p < 0.001). There has been a significant increase (1973–1982 vs. 2004–2013) in median OS (7 months vs. 10 months, p < 0.001) and median ECSS (7 months vs. 11 months, p < 0.001) among UEC patients from 1973 to 2013. For the impact of different treatments, the results showed that the ECSS and OS of surgery without radiation (SWR) and radiation plus surgery (R+S) were superior to those of radiation without surgery (RWS). Subgroup analysis showed that ECSS and OS were highest among patients treated with SWR compared with R+S and RWS for patients with localized disease. For regional disease, ECSS and OS were highest among patients with R+S compared with SWR or RWS. Among patients with regional-stage squamous cell carcinoma (SCC), OS was higher with neoadjuvant radiotherapy or adjuvant radiotherapy compared with SWR. Multivariate analysis showed that radiotherapy sequence was dependently associated with OS among patients with regional-stage SCC.
Conclusion
Although the long-term survival of UEC remains poor, it has gradually increased since 1973. This should be closely related to the improvement of medical care over the past 40 years. Different treatment methods have a great influence on the long-term survival of UEC. For localized diseases, surgery may be a better choice. For regional disease, surgery plus adjuvant or neoadjuvant radiotherapy may be more beneficial to improve the long-term prognosis of UEC patients.
... After revision of title and abstract, 135 studies were included for full-text assessment. After applying the abovementioned inclusion and exclusion criteria, 22 articles (Burmeister et al. 2000;Cao et al. 2016;Chen et al. 2020;Gkika et al. 2014;Herrmann et al. 2017;Inada et al. 2021;Ito et al. 2017;Kim et al. 2019;Li et al. 2018;McDowell et al. 2017;Nakata et al. 2017;Okamoto et al. 2018;Sakanaka et al. 2018;Takebayashi et al. 2017;Tong et al. 2011;Uno et al. 2007;Yamada et al. 2006;Yang et al. 2017;Zenda et al. 2016;Zhang et al. 2015;Zhao et al. 2017Zhao et al. , 2020 were included in the qualitative and quantitative synthesis. The reasons behind the exclusions of 113 studies are shown in Fig. 1. ...
... In fact, patients rarely accept to be randomized between surgical (National Institute for Health and Care Excellence 2012) and non-surgical approaches in case of an oncological disease. Furthermore, only few retrospective studies directly comparing CRT and surgery are available (Takebayashi et al. 2017;Tong et al. 2011), and no pooled analysis could be performed. As a consequence, cumulative single-arm retrospective analysis is the strongest level of evidence that could be extracted from Content courtesy of Springer Nature, terms of use apply. ...
Purpose
To determine the oncological outcomes of cervical esophageal squamous cell carcinoma (CESCC) treated with definitive chemoradiotherapy (CRT).
Methods
A systematic review and meta-analysis was performed according to the PRISMA guidelines.
Results
A total of 1222 patients (median age: 63.0 years, 95% CI 61.0–65.0) were included from 22 studies. The median follow-up time was 34.0 months (n = 1181, 95% CI 26.4–36.0). Estimated pooled OS rates (95% CI) at 1, 3, and 5 years were 77.9% (73.9–82.2), 48.4% (43.2–54.3), and 35.3% (29.7–41.9), respectively. The median OS (95% CI) was 33.4 months (25.8–42.2). Estimated pooled PFS rates (n = 595; 95% CI) at 1, 3, and 5 years were 64.1% (57.9–71.0), 38.0% (33.3–45.5), and 29.8% (23.9–37.1), respectively. The median PFS (95% CI) was 19.8 months (14.9–26.6).
Conclusions
Definitive CRT is a valuable first-line treatment for the management of CESCC. Further studies should focus on survival predictors able to define stage-based clinical guidelines.
... Frontiers in Surgery recurrence, anastomotic recurrence or underwent postoperative supplementary radiation, were excluded (12,13). Even though, 10.9% of PELLNR cases were still observed. ...
Objectives
Even underwent radical resection, some patients of thoracic esophageal squamous cell carcinoma (ESCC) are still exposed to local recurrence in a short time. To this end, the present study sought to differentiate patient subgroups by assessing risk factors for postoperative early (within one year) local lymph node recurrence (PELLNR).
Methods
ESCC patients were selected from a prospective database, and divided into high- and low-risk groups according to the time of their local lymphatic recurrence (within one year or later). Survival analysis was conducted by the Cox regression model to evaluate the overall survival (OS) between the two groups. The hazard ratio (HR) and 95% confidence interval (CI) of different variables were also calculated. Logistic regression analysis was used to explore the high-risk factors for PELLNR with the odds ratio (OR) and 95% CI calculated.
Results
A total of 432 cases were included. The survival of patients in the high-risk group ( n = 47) was significantly inferior to the low-risk group ( n = 385) (HR = 11.331, 95% CI: 6.870–16.688, P < 0.001). The 1-year, 3-year, and 5-year OS rate of the patients in high/low-risk groups were 74.5% vs. 100%, 17% vs. 88.8%, and 11.3% vs. 79.2%, respectively ( P < 0.001). Risk factors for local lymph node recurrence within one year included upper thoracic location (OR = 4.071, 95% CI: 1.499–11.055, P = 0.006), advanced T staging (pT3–4, OR = 3.258, 95% CI: 1.547–6.861, P = 0.002), advanced N staging (pN2–3, OR = 5.195, 95% CI: 2.269–11.894, P < 0.001), and neoadjuvant treatment (OR = 3.609, 95% CI: 1.716–7.589, P = 0.001). In neoadjuvant therapy subgroup, high-risk group still had unfavorable survival (Log-rank P < 0.001). Multivariate analysis demonstrated that upper thoracic location (OR = 5.064, 95% CI: 1.485–17.261, P = 0.010) and advanced N staging (pN2–3) (OR = 5.999, 95% CI: 1.986–18.115, P = 0.001) were independent risk factors for early local lymphatic recurrence. However, the cT downstaging (OR = 0.862, 95% CI: 0.241–3.086, P = 0.819) and cN downstaging (OR = 0.937, 95% CI: 0.372–2.360, P = 0.890) for patients in the neoadjuvant subgroup failed to lower PELLNR. The predominant recurrence field type was single-field.
Conclusions
Thoracic ESCC patients with lymph node recurrence within one year delivered poor outcomes, with advanced stages (pT3–4/pN2–3) and upper thoracic location considered risk factors for early recurrence.
Although free-flap jejunal reconstruction is frequently performed after cervical esophagectomy for cervical esophageal cancer, the procedure after gastric surgery has not been reported. We encountered two patients with esophageal cancer and previous gastric surgeries who eventually underwent segmental esophagectomy with free-flap jejunal reconstruction. Case one involved a 75-year-old man who underwent abdominal abscess and duodenal ulcer perforation surgeries (abdominal drainage and subsequent gastrojejunal bypass). A type 0-IIa tumor was located posterior to the cervical esophagus's right wall, 21 cm from the incisor, without lymph node swelling or distant metastasis. The left lobe of the thyroid gland was mobilized to ensure an oral resection margin. Severe abdominal adhesions required careful adhesiolysis to harvest the jejunum (20 cm long) 40 cm from the jejunojejunostomy. An end-to-side and side-to-end esophagojejunostomy were performed for the proximal and distal ends, respectively. Case two involved a 75-year-old male with a history of distal gastrectomy with Billroth I reconstruction for early gastric cancer. A submucosal tumor-like lesion was located on the cervical esophageal wall on the left side, 21 cm from the incisor. The distal esophagus required additional segmental resection because the anal resection line was close to the tumor. Jejunum (10 cm long) 30 cm from Ligament of Treitz was harvested. An end-to-side and end-to-end esophagojejunostomy for the proximal and distal ends, respectively, was performed. This surgery requires a thorough preoperative examination to ensure an adequate surgical margin and a careful free-flap harvest based on post-gastric surgery anatomy.
Background
Cervical esophageal cancer accounts for a small proportion of all esophageal cancers. Therefore, studies examining this cancer include a small patient cohort. Most patients with cervical esophageal cancer undergo reconstruction using a gastric tube or free jejunum after esophagectomy. We examined the current status of postoperative morbidity and mortality of cervical esophageal cancer based on big data.Methods
Based on the Japan National Clinical Database, 807 surgically treated patients with cervical esophageal cancer were enrolled between January 1, 2016, and December 31, 2019. Surgical outcomes were retrospectively reviewed for each reconstructed organ using gastric tubes and free jejunum.ResultsThe incidence of postoperative complications related to reconstructed organs was higher in the gastric tube reconstruction (17.9%) than in the free jejunum (6.7%) for anastomotic leakage (p < 0.01), but not significantly different for reconstructed organ necrosis (0.4% and 0.3%, respectively). The incidence rates of overall morbidity, pneumonia, 30-day reoperation, tracheal necrosis, and 30-day mortality using these reconstruction methods were 64.7% and 59.7%, 16.7% and 11.1%, 9.3% and 11.4%, 2.2% and 1.6%, and 1.2% and 0.0%, respectively. Only pneumonia was more common in the gastric tube reconstruction group (p = 0.03), but was not significantly different for any other complication.Conclusions
The incidence of overall morbidities and reoperation, especially anastomotic leakage after gastric tube reconstruction, suggested a necessity for further improvement. However, the incidence of fatal complications, such as tracheal necrosis or reconstructed organ necrosis, was low for both reconstruction methods, and the mortality rate was acceptable as a means of radical treatment.
Esophageal cancer is one of the hardest to treat malignant cancers. Patient prognosis remains unsatisfactory despite considerable progress in surgical, radiation, and drug treatments. Surgery remains the main form of treatment for this pathology as it is the only radical treatment method. The objective is to evaluate short-term treatment results for cancer of the cervical esophagus and laryngopharynx after large-scale resection with reconstruction and plastic surgery stage. A clinical case of locally advanced squamous cell carcinoma of the mucosa of the cervical esophagus is presented. Use of free radial fasciocutaneous flap for reconstruction of the cervical esophagus with preservation of the pharynx is described. Problems of diagnosis and surgical treatment of this pathology from the point of view of our clinic’s experience are considered. We show that radial forearm flap can be used for reconstruction of the pharynx and cervical esophagus during circular resections.
The American Joint Committee on Cancer's Cancer Staging Manual is used by physicians throughout the world to diagnose cancer and determine the extent to which cancer has progressed. All of the TNM staging information included in this Sixth Edition is uniform between the AJCC (American Joint Committee on Cancer) and the UICC (International Union Against Cancer).
In addition to the information found in the Handbook, the Manual provides standardized data forms for each anatomic site, which can be utilized as permanent patient records, enabling clinicians and cancer research scientists to maintain consistency in evaluating the efficacy of diagnosis and treatment. The CD-ROM packaged with each Manual contains printable copies of each of the book’s 45 Staging Forms.
PURPOSEA prospective study was performed to determine the outcome of patients with esophageal cancer who received preoperative radiation therapy and chemotherapy followed by esophagectomy, and to determine the role of preresection esophagogastroduodenoscopy (EGD) in predicting the patients in whom surgery could possibly be omitted, and the impact of surgery on survival.MATERIALS AND METHODS
Thirty-five patients with localized carcinoma of the esophagus received concurrent external-beam radiotherapy and chemotherapy followed by esophagectomy. Patients received 45 Gy in 25 fractions. Chemotherapy consisted of continuous infusion fluorouracil (5-FU; 1,000 mg/m2/d) on days 1 through 4 and 29 through 32 and cisplatin (100 mg/m2) on day 1. Patients underwent an Ivor-Lewis esophagectomy 18 to 33 days after completion of radiotherapy.RESULTSEighty percent of the patients had squamous cell carcinoma and 20% had adenocarcinoma. In addition, 51% had a pathologic complete response (CR). Twenty-two of the 35 underwent ...
PURPOSEThe present intergroup phase III randomized study compared combined chemotherapy (CT) plus radiotherapy (RT) treatment versus RT only in patients with locally advanced esophageal cancer.MATERIALS AND METHODS
Two courses of chemotherapy during 50 Gy RT followed by additional two courses of the same CT, versus 64 Gy RT alone were investigated. CT consisted of cisplatin 75 mg/m2 on day 1 [corrected] and fluorouracil (5FU) 1,000 mg/m2/d on days 1 to 4 every 4 weeks with RT and every 3 weeks post-RT. The main objective of the study was to compare overall survival between the two randomized treatment groups. Patients were stratified by tumor size, histology, and degree of weight loss.RESULTSSixty-two assessable patients were randomized to receive RT alone, and 61 to the combined arm. Patients characteristics were as follows: squamous cell cancer, 90% versus 85%; weight loss greater than 10 lb, 61% versus 69%; and tumor size, > or = 5 cm, 82% versus 80% on the RT and CT-RT arms, respectively. Systemic side...
PURPOSE: A pilot study of 43 patients with potentially resectable esophageal carcinoma treated with an intensive regimen of preoperative chemoradiation with cisplatin, fluorouracil, and vinblastine before surgery showed a median survival of 29 months in comparison with the 12-month median survival of 100 historical controls treated with surgery alone at the same institution. We designed a randomized trial to compare survival for patients treated with this preoperative chemoradiation regimen versus surgery alone.
MATERIALS AND METHODS: One hundred patients with esophageal carcinoma were randomized to receive either surgery alone (arm I) or preoperative chemoradiation (arm II) with cisplatin 20 mg/m²/d on days 1 through 5 and 17 through 21, fluorouracil 300 mg/m²/d on days 1 through 21, and vinblastine 1 mg/m²/d on days 1 through 4 and 17 through 20. Radiotherapy consisted of 1.5-Gy fractions twice daily, Monday through Friday over 21 days, to a total dose of 45 Gy. Transhiatal esophagectomy with a cervical esophagogastric anastomosis was performed on approximately day 42.
RESULTS: At median follow-up of 8.2 years, there is no significant difference in survival between the treatment arms. Median survival is 17.6 months in arm I and 16.9 months in arm II. Survival at 3 years was 16% in arm I and 30% in arm II (P = .15). This study was statistically powered to detect a relatively large increase in median survival from 1 year to 2.2 years, with at least 80% power.
CONCLUSION: This randomized trial of preoperative chemoradiation versus surgery alone for patients with potentially resectable esophageal carcinoma did not demonstrate a statistically significant survival difference.
PURPOSE: To compare the local/regional control, survival, and toxicity of combined-modality therapy using high-dose (64.8 Gy) versus standard-dose (50.4 Gy) radiation therapy for the treatment of patients with esophageal cancer.
PATIENTS AND METHODS: A total of 236 patients with clinical stage T1 to T4, N0/1, M0 squamous cell carcinoma or adenocarcinoma selected for a nonsurgical approach, after stratification by weight loss, primary tumor size, and histology, were randomized to receive combined-modality therapy consisting of four monthly cycles of fluorouracil (5-FU) (1,000 mg/m²/24 hours for 4 days) and cisplatin (75 mg/m² bolus day 1) with concurrent 64.8 Gy versus the same chemotherapy schedule but with concurrent 50.4 Gy. The trial was stopped after an interim analysis. The median follow-up was 16.4 months for all patients and 29.5 months for patients still alive.
RESULTS: For the 218 eligible patients, there was no significant difference in median survival (13.0 v 18.1 months), 2-year survival (31% v 40%), or local/regional failure and local/regional persistence of disease (56% v 52%) between the high-dose and standard-dose arms. Although 11 treatment-related deaths occurred in the high-dose arm compared with two in the standard-dose arm, seven of the 11 deaths occurred in patients who had received 50.4 Gy or less.
CONCLUSION: The higher radiation dose did not increase survival or local/regional control. Although there was a higher treatment-related mortality rate in the patients assigned to the high-dose radiation arm, it did not seem to be related to the higher radiation dose. The standard radiation dose for patients treated with concurrent 5-FU and cisplatin chemotherapy is 50.4 Gy.
Fifty-one untreated patients with advanced squamous cell carcinoma of the thoracic esophagus were entered into a randomized prospective study. The patients were randomized into four study groups for intraluminal brachytherapy. Group A patients (n=12) received treatment with 10 Gy; group B (n=14), 12 Gy; group C (n=14), 15 Gy; and group D (n=11), 18 Gy of single- fraction high dose rate intraluminal brachytherapy. The patients were followed up every month for four months. Relief of dysphagia and weight gain were seen in all evaluable patients in groups B and C; improvement of performance status was seen in all evaluable patients in group C in the third and fourth month. Four patients (two in group A and two in group B) developed stricture due to persistent disease after three months of follow-up. Four patients developed fibrotic strictures (one in group C and three in group D) within four months of follow-up. One patient in group D developed tracheoesophageal fistula and required intubation. Single-fraction high dose rate intraluminal brachytherapy of 12 to 15 Gy is likely to give the best results in terms of relief from dysphagia, weight gain, and improvement of performance status. Patients receiving this dose range should experience the least morbidity in terms of strictures and fistulae in palliation of advanced carcinoma of the esophagus.
BACKGROUND: Issues have arisen regarding H. pylori infection and GERD that have caused unnecessary confusion among practicing physicians. In the last century GERD became increasingly recognized in the West and it has become evident that the prevalence of GERD is now occurring in many previously underdeveloped countries. METHODS: This review article fosters understanding of the issues by focusing on the esophageal acid load and the factors that control it. In particular, we discuss the effects of the change in the patterns of gastritis that have occurred naturally as well as after H. pylori eradication and correlate those changes with their effects on the esophageal acid load. We show how it is possible to separate gastroesophageal reflux from gastroesophageal reflux disease based on differences in esophageal acid load. We also describe how the practice of assessing gastroesophageal reflux based on the time the intraesophageal pH is less than 4 resulted in investigators systematically discarding data critical to understanding of the effect of their interventions on esophageal acid load. Testable hypotheses are presented to explain the interactions between H. pylori and GERD and between H. pylori and the changing epidemiology of GERD. CONCLUSIONS: We propose that the confusion regarding H. pylori and the changing epidemiology of GERD is based on the failure to critically examine the historical evidence in relation to the other H. pylori-related diseases as well as reliance on techniques that are either unable to measure, or systematically discard data critical for understanding effects of various interventions on the esophageal acid load. This has resulted in propagation of erroneous concepts regarding H. pylori and adenocarcinoma of the esophagus and has resulted in some patients being denied appropriate therapy. (C) 2003 by Am. Coll. of Gastroenterology.
