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Adenocarcinoma of the esophagus and cardia
J
THoRAc CARDIOVASC SURG
1987;94:64-8
Adenocarcinoma of the esophagus and cardia Two hundred thirty-nine patients with carcinoma of the esopbagus and cardia were seen between 1971 and 1985. Of 128 adenocarcinomas, lOS (84%) were resected. There were III squamoWiceU tumors, of which 104 (94%) were resected. Hospital mortality rate (3 months) was 19.4% in patients with adenocarcinoma and 14.4 % in those with squamoWiceUcarcinoma. It was significantly higber in the over 70 age group in both series. The 1 year survival rate in the adenocarcinoma group (52.3%) was lower than in the squamous group (59.1 %), which reflects the higber operative mortality rate in the former. The 5 year survival rate was 18% in the adenocarcinoma group and 18.7% in the squamoWi ceU group. With one exception, aU patients who survived for 5 years bad a Stage I tumor. Although the operative mortality was higher in the adenocarcinoma group, the prognosis was similar to that of the squamous ceU carcinoma group.
T. P. J. Hennessy, M.Ch., F.R.C.S., F.R.C.S.I., and P. Keeling, M.Ch., F.R.C.S.I., Dublin, Ireland
Adenocarcinoma of the esophagus and cardia comprises a heterogenous group of tumors that include the rare adenoid cystic carcinoma, tumors arising from deep mucous glands of the esophagus, those arising from the ectopic epithelium of Barrett's esophagus, and tumors of gastric origin invading the esophagus from below. Despite their varied origin they present a similar clinical picture and possess a common natural history. Adenocarcinomas of the cardia are generally regarded as having a bad prognosis with a low resectability rate! and a consistently poor 5 year survival rate." Giuli and Lortat-Jacob,' in a review of the late results of operations for carcinoma of the esophagus and cardia, reported that no patient with adenocarcinoma had survived 5 years. Webb and Busuttil" postulated an intrinsic biological aggressiveness in these tumors which, in additioin to their complex anatomical site and extensive lymphatic drainage above and below the diaphragm, contributed to their poor survival rate. Despite the ultimate prognosis, many authors report a low operative mortality rate for adenocarcinoma of the cardia. Gunlaugsson and colleagues,' in an analysis of
From the Department of Surgery, Trinity College Dublin at St. James's Hospital, Dublin, Ireland. Received for publication April I, 1986. Accepted for publication July 8, 1986. Address for reprints: Professor T. P. J. Hennessy, Department of Surgery, St. James's Hospital, Dublin, 8, Ireland.
64
Table I. Operative mortality (3 months) in 212 patients undergoing resection Mortality (%)
Adenocarcinoma Total squamous carcinoma Middle third squamous Lower third squamous
19.4 14.4
49
8
16.3
55
7
12.7
the Mayo Clinic experience, gave a figure of 12.3%,and Mckeown" reported a mortality rate of 5.6% in a personal series. Earlam and Cunha-Melo? believed that a mortality rate well under 10% could be expected in most series. However, Webb and Busuttil" reported a mortality rate of 32% and Lortat-Jacob and associates" found a perioperative death rate of 20%. Published reports on carcinoma of the esophagus and cardia are often confusing, because histologic separation of adenocarcinomas and squamous cell carcinomas is sometimes ignored. Furthermore, at least one group of authors II has stated that histologic type does not affect the outcome of operation and that tumors in this region should be classified and reported as a single entity. The aim of this paper is to review our experience with adenocarcinomas of the esophagus and cardia and to compare the results of operation with those of squamous
Volume 94 Number 1
Adenocarcinoma of esophagus and cardia
July 1987
65
Table II. Cause of death Squamous Adenocarcinoma Myocardial infarction Anastomotic leak Sepsis Cardiac arrhythmia Pulmonary embolism Hemorrhage Cachexia and disseminated tumor Chest infection Pneumothorax Total
Middle third
5
3
3 2 I 3 I
2
2 3 I 21
cell tumors of the lower and middle thirds of the esophagus.
Pathology Postresectional staging of the tumor was conducted according to the TNM classification recommended by
Total 9 6 3 I 5 2
2
2 7 I 36
3 8
7
Table ill. Complications Squamous
Patients During the period 1971 to 1985, 239 patients with carcinoma of the esophagus and cardia were referred to ourdepartment. One hundred twenty-eight patients had an adenocarcinoma, and 108 (84%) of them underwent resection of the tumor. Of the 20 patients who did not undergo resection, two were submitted to exploration but resection was impossible because of extensive local tumor spread. The remaining 18 patients did not have an exploratory operation because of severe cardiac or respiratory disease or widely disseminated tumor confirmed by chest x-ray film or liver scan. These unresectable tumors were treated by either intubation or intermittent dilatation, except in one patient in whom a bypass procedure was employed. Of the 111 patients with a squamous cell tumor seen during the same period, 104 (94%) underwent resection of the tumor. Thus although it is not possible to exclude some element of pre-selection before referral to the hospital, our policy has been to favor an aggressive surgical approach: Of the 239 patients referred to us, 212 underwent resection, for an overall resection rate of 88%. Patientsages ranged between 27 and 80 years, but the mean age was similar in both groups (adenocarcinoma 65 years, squamous cell carcinoma 63 years). The male:female ratio in adenocarcinoma was 3:1 and in squamous cell tumor 1.5:1. Histologic confirmation of the diagnosis was obtained in all patients in both groups.
Lower third
I
Nonfatal anastomotic leaks Benign strictures Gastric stasis Recurrence at anastomosis
Adenocarcinoma
3
2
II
o
4
Total
7 3
8
18 3 12
the American Joint Committee on Cancer. Only 5% of all tumors were Stage I. Therefore, Stage I and II tumors were grouped together. In the adenocarcinoma group 21.3% of tumors were Stage I and II and 78.7% were Stage III. In the squamous cell group 49% were Stage I and II and 51 % were Stage III. Tumor site Tumors of the lower third of the esophagus were defined anatomically as being located between the cardia and the inferior pulmonary vein. The majority of adenocarcinomas were situated at the cardia or in the lower third of the esophagus. Middle-third tumors were defined as those lying between the inferior pulmonary vein and the arch of the aorta. Most middle-third tumors were squamous in origin but a small number (n = 7) were adenocarcinomas, one of which was an adenoid cystic tumor. Barrett's esophagus Sixteen tumors were associated with Barrett's epithelium in the esophagus. Fifteen of these were adenocarcinomas and one was a squamous cell carcinoma. The operative mortality rate for these patients was higher (25%) than for adenocarcinoma group as a whole
The Journal of Thoracic and Cardiovascular
6 6 Hennessy and Keeling
100
% 80
Surgery
I
~r
t ...
ADEND SQUAMOUS . - .
: I ~.
60
40
1- _e
L.-.
:- - .!
~.
1_-
~
I
20
.
I
I
,- - - - - - !l-:--_-_-_----_: -::_--:_:--::"-=--=-
OL.L...."=-l..-.---I 1
.L--_ _....r._ _- - - I
-J-
3
2
4
5
YEARS
Fig. 1. Life-table analysis showing survival in patients with adenocarcinoma and squamous carcinoma.
(19.4%) and the prognosis was worse, with a mean survival time of 9 months. Operative technique The Lewis-Tanner two-stage technique was used for the majority of middle-third tumors. McKeown's threephase technique" was used for the higher middle-third tumors. Lower-third tumors were resected by the LewisTanner technique, but some were approached through separate midline epigastric and left thoracotomy incisions. The majority of tumors of the cardia were resected by the latter approach with antroesophageal anastomosis. For tumors with extensive gastric involvement the entire stomach was included in the resection. Pyloroplasty was not performed unless narrowing of the gastric outlet was noted. All anastomoses were made by hand and staplers were not employed. Results Mortality. The operative mortality rate for all patients in the adenocarcinoma group undergoing resection was 19.4% (Table I). If the 16 patients with Barrett's esophagus are excluded, the mortality rate in the remaining 92 patients with adenocarcinoma was 18.4%. The overall mortality rate for all patients with squamous cell tumor undergoing resection was 14.4%. For patients with a middle-third squamous cell tumor the mortality rate was 16.3%, and for those with a lower-third tumor, 12.7%. The individual cause of death
is given in Table II for both groups. There were six deaths from anastomotic leak, three in the adenocarcinoma group and three in the squamous cell group. Both groups had a high incidence of postoperative myocardial infarction, which was the most frequent cause of death. The incidence of fatal postoperative chest infection was also similar in the two groups. A greater number of deaths caused by cardiac arrhythmia, sepsis, and cachexia occurred in the adenocarcinoma group. Age was an important factor in the operative mortality in both groups. Nine of 34 patients over 70 years of age with adenocarcinoma died (26.4%). Of the 74 patients with adenocarcinoma under 70 years of age, 12 died postoperatively (16%). Thirty-five patients over 70 years old had squamous cell carcinoma, of whom eight died (22.8%). In the under 70 group, seven of 69 patients with squamous cell tumors died (10.1%). Improved intensive care facilities, better anesthetic techniques, and increasing experience had a significant effect on the mortality figures in the latter part of the series. During the period 1971 to 1978, a total of 27 adenocarcinomas and 35 squamous cell carcinomas were resected, for mortality rates of 25.9% and 20%, respectively. From 1979 to 1985, a total of 150 patients underwent resection; 81 had adenocarcinomas and 69 had squamous cell tumors. During this period the mortality rate for adenocarcinomas fell to 17.2%and the mortality rate for squamous cell tumors dropped to 11.5%.
Volume 94 Number 1 July 1987
Morbidity. Postoperative complications are shown in Table III. Nonfatal anastomotic leaks occurred in three patients. All closed with conservative management and reexploration was not required. Some degree of stenosis necessitating dilatation developed at the anastomosis in 18 patients. In two of these patients, dilatation proved inadequate and the anastomosis had to be restructured. Pyloroplasty for persistent gastric stasis was necessary in three patients. Local recurrence developed in 12 patients, eight of whom were in the adenocarcinoma group. Two were treated by colon bypass, two by radiotherapy, and the remainder by intubation or intermittent dilatation. Survival Actuarial survival data are presented in Fig. 1. The 1 year survival rate in the adenocarcinoma group was 52.3% and in the squamous cell carcinoma group, 59.1 %. The 5 year survival rate in the adenocarcinoma group was 18% and in the squamous cell group, 18.7%. All 5 year survivors had Stage I tumors except for one patient with a Stage III squamous cell carcinoma. Discussion In this series of patients, adenocarcinoma of the esophagus and cardia presented with the same frequency as squamous cell carcinoma of the esophagus. The ratio of men to women, however, was twice that of the squamous cell group. The mean age of the two groups was the same and the duration of symptoms in both groups was similar. Nevertheless, the adenocarcinomas included a higher percentage of Stage III tumors. This would seem to suggest that dysphagia is a later manifestation in adenocarcinoma than in squamous cell carcinoma. Mortality statistics include all hospital deaths up to 3 months. The overall mortality rate of 17% contrasts unfavorably with such recently reported series as those of Ellis, 13 Akiyama," and their associates, whose mortality rates were 1.3% and 1.4%, respectively. However, Ellis, Gibb, and Watkins" have rightly pointed out that comparisons of the surgical results from different institutions may not always be valid, because of the different populations involved. Mortality rates of a similar order to this series (21%) have been reported by Van Andel, Dees, and Dijkhins." The high resectability rate as a consequence of our aggressive bias toward resection and the heavy mortality in the early part of these series account in part for the high overall mortality rate. The prevalence of chronic respiratory problems and cardiovascular disease in our general patient population is an additional contributory factor. The inclusion of all
Adenocarcinoma of esophagus and cardia
67
hospital deaths up to 3 months inevitably tends to produce higher mortality figures than the conventional 30 day mortality frequently employed. The 1 year survival rate in the adenocarcinoma group was not as good as in the squamous group, but the difference was largely due to the higher operative mortality in the adenocarcinoma group. The 5 year survival rates in both groups depended on the tumor stage. When the tumor was small and lymph nodes were not involved, 5 year survival was achieved by patients with adenocarcinomas and lower-third squamous tumors. Squamous cell tumors of the middle third had a particularly bad prognosis. This prognosis might have been improved had more three-phase procedures been performed. The results suggest that there is no inherent biological aggressiveness in adenocarcinomas and that the poor survival rate usually attributed to the tumors is simply a reflection of late diagnosis. Because of the lack of any worthwhile alternative to operation in treating adenocarcinomas, it is important to realize that despite their late presentation a small number of these patients are potential long-term survivors. REFERENCES I. Miller C. Carcinoma of the thoracic oesophagus and
cardia. Br J Surg 1962;49:507-22. 2. Ellis FH Jr, Maggs PRo Surgery for carcinoma of the lower oesophagus and cardia. World J Surg 1981;5:52733. 3. Skinner DB. Esophageal malignancies: experience with 110 cases. Surg Clin North Am 1976;65:137-47. 4. Griffith JL, Davis JT. A twenty year experience with surgical management of carcinoma of the esophagus and gastric cardia. J THORAC CARDIOVASC SURG 1980;79:44752. 5. Giuli R, Lortat-Jacob JL. Long term results in surgical treatment of oesophageal carcinoma. In: Silber W, ed. Carcinoma of the oesophagus. Rotterdam, Capetown: Balkema, 1978:390-412. 6. Webb IN, Busuttil A. Adenocarcinomaof the oesophagus and of the oesophago-gastric junction. Br J Surg 1978; 65:475-9. 7. Gunlaugsson GH, Wychulis AR, Roland C, Ellis FH. Analysisof the recordsof 1657 patients with carcinoma of the oesophagus and cardia of the stomach. Surg Gynecol Obstet 1970;130:997-1006. 8. McKeown KC. Carcinoma of the oesophagus. J R Coll Surg Edin 1979;24:253-74. 9. Earlam R, Cunha-Melo JR. Oesophageal squamous cell carcinoma: a critical review of surgery. Br J Surg 1980; 67:381-90. 10. Lortat-Jacob JL, Maillard IN, Richard CA, Fekete F, Lanois B. Surgical treatment of cancer of the oesophagus. Br J Clin Pract 1970;24: 13-8.
68
Hennessy and Keeling
11. Stone R, Rangel OM, Gordon HE, Wilson SE. Carcinoma of the gastroesophageal junction. Am J Surg 1977;134:70-6. 12. McKeown KC. Total three-stage oesophagectomy for cancer of the oesophagus. Br J Surg 1976;63:259-62. 13. Ellis FH Jr, Gibb SP, Watkins E Jr. Esophagogastrectomy: a safe, widely applicable and expeditious form of palliation for patients with carcinoma of the esophagus and cardia. Ann Surg 1983;198:531-9.
The Journal of Thoracic and Cardiovascular Surgery
14. Akiyama H, Tsurumaru M, Kawanura T, Ono y. Principles of surgical treatment for carcinoma of the esophagus: analysis of lymph node involvement. Ann Surg 1981; 194:438-46. 15. Van Andel JG, Dees J, Oijkhins CM. Carcinoma of the esophagus: results of treatment. Ann Surg 1979;190: 684-9.
Bound volumes available to subscribers Bound volumes of THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY are available to subscribers (only) for the 1987 issues from the Publisher, at a cost of $49.00 ($66.00 international) for Vol. 93 (January-June) and Vol. 94 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue of the volume. The binding is durable buckram with the JOURNAL name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact The C. V. Mosby Company, Circulation Department, 11830 Westline Industrial Drive, St. Louis, Missouri 63146, USA; phone (800) 325-4177, ext. 351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular JOURNAL subscription.
THoRAc CARDIOVASC SURG
1987;94:64-8
Adenocarcinoma of the esophagus and cardia Two hundred thirty-nine patients with carcinoma of the esopbagus and cardia were seen between 1971 and 1985. Of 128 adenocarcinomas, lOS (84%) were resected. There were III squamoWiceU tumors, of which 104 (94%) were resected. Hospital mortality rate (3 months) was 19.4% in patients with adenocarcinoma and 14.4 % in those with squamoWiceUcarcinoma. It was significantly higber in the over 70 age group in both series. The 1 year survival rate in the adenocarcinoma group (52.3%) was lower than in the squamous group (59.1 %), which reflects the higber operative mortality rate in the former. The 5 year survival rate was 18% in the adenocarcinoma group and 18.7% in the squamoWi ceU group. With one exception, aU patients who survived for 5 years bad a Stage I tumor. Although the operative mortality was higher in the adenocarcinoma group, the prognosis was similar to that of the squamous ceU carcinoma group.
T. P. J. Hennessy, M.Ch., F.R.C.S., F.R.C.S.I., and P. Keeling, M.Ch., F.R.C.S.I., Dublin, Ireland
Adenocarcinoma of the esophagus and cardia comprises a heterogenous group of tumors that include the rare adenoid cystic carcinoma, tumors arising from deep mucous glands of the esophagus, those arising from the ectopic epithelium of Barrett's esophagus, and tumors of gastric origin invading the esophagus from below. Despite their varied origin they present a similar clinical picture and possess a common natural history. Adenocarcinomas of the cardia are generally regarded as having a bad prognosis with a low resectability rate! and a consistently poor 5 year survival rate." Giuli and Lortat-Jacob,' in a review of the late results of operations for carcinoma of the esophagus and cardia, reported that no patient with adenocarcinoma had survived 5 years. Webb and Busuttil" postulated an intrinsic biological aggressiveness in these tumors which, in additioin to their complex anatomical site and extensive lymphatic drainage above and below the diaphragm, contributed to their poor survival rate. Despite the ultimate prognosis, many authors report a low operative mortality rate for adenocarcinoma of the cardia. Gunlaugsson and colleagues,' in an analysis of
From the Department of Surgery, Trinity College Dublin at St. James's Hospital, Dublin, Ireland. Received for publication April I, 1986. Accepted for publication July 8, 1986. Address for reprints: Professor T. P. J. Hennessy, Department of Surgery, St. James's Hospital, Dublin, 8, Ireland.
64
Table I. Operative mortality (3 months) in 212 patients undergoing resection Mortality (%)
Adenocarcinoma Total squamous carcinoma Middle third squamous Lower third squamous
19.4 14.4
49
8
16.3
55
7
12.7
the Mayo Clinic experience, gave a figure of 12.3%,and Mckeown" reported a mortality rate of 5.6% in a personal series. Earlam and Cunha-Melo? believed that a mortality rate well under 10% could be expected in most series. However, Webb and Busuttil" reported a mortality rate of 32% and Lortat-Jacob and associates" found a perioperative death rate of 20%. Published reports on carcinoma of the esophagus and cardia are often confusing, because histologic separation of adenocarcinomas and squamous cell carcinomas is sometimes ignored. Furthermore, at least one group of authors II has stated that histologic type does not affect the outcome of operation and that tumors in this region should be classified and reported as a single entity. The aim of this paper is to review our experience with adenocarcinomas of the esophagus and cardia and to compare the results of operation with those of squamous
Volume 94 Number 1
Adenocarcinoma of esophagus and cardia
July 1987
65
Table II. Cause of death Squamous Adenocarcinoma Myocardial infarction Anastomotic leak Sepsis Cardiac arrhythmia Pulmonary embolism Hemorrhage Cachexia and disseminated tumor Chest infection Pneumothorax Total
Middle third
5
3
3 2 I 3 I
2
2 3 I 21
cell tumors of the lower and middle thirds of the esophagus.
Pathology Postresectional staging of the tumor was conducted according to the TNM classification recommended by
Total 9 6 3 I 5 2
2
2 7 I 36
3 8
7
Table ill. Complications Squamous
Patients During the period 1971 to 1985, 239 patients with carcinoma of the esophagus and cardia were referred to ourdepartment. One hundred twenty-eight patients had an adenocarcinoma, and 108 (84%) of them underwent resection of the tumor. Of the 20 patients who did not undergo resection, two were submitted to exploration but resection was impossible because of extensive local tumor spread. The remaining 18 patients did not have an exploratory operation because of severe cardiac or respiratory disease or widely disseminated tumor confirmed by chest x-ray film or liver scan. These unresectable tumors were treated by either intubation or intermittent dilatation, except in one patient in whom a bypass procedure was employed. Of the 111 patients with a squamous cell tumor seen during the same period, 104 (94%) underwent resection of the tumor. Thus although it is not possible to exclude some element of pre-selection before referral to the hospital, our policy has been to favor an aggressive surgical approach: Of the 239 patients referred to us, 212 underwent resection, for an overall resection rate of 88%. Patientsages ranged between 27 and 80 years, but the mean age was similar in both groups (adenocarcinoma 65 years, squamous cell carcinoma 63 years). The male:female ratio in adenocarcinoma was 3:1 and in squamous cell tumor 1.5:1. Histologic confirmation of the diagnosis was obtained in all patients in both groups.
Lower third
I
Nonfatal anastomotic leaks Benign strictures Gastric stasis Recurrence at anastomosis
Adenocarcinoma
3
2
II
o
4
Total
7 3
8
18 3 12
the American Joint Committee on Cancer. Only 5% of all tumors were Stage I. Therefore, Stage I and II tumors were grouped together. In the adenocarcinoma group 21.3% of tumors were Stage I and II and 78.7% were Stage III. In the squamous cell group 49% were Stage I and II and 51 % were Stage III. Tumor site Tumors of the lower third of the esophagus were defined anatomically as being located between the cardia and the inferior pulmonary vein. The majority of adenocarcinomas were situated at the cardia or in the lower third of the esophagus. Middle-third tumors were defined as those lying between the inferior pulmonary vein and the arch of the aorta. Most middle-third tumors were squamous in origin but a small number (n = 7) were adenocarcinomas, one of which was an adenoid cystic tumor. Barrett's esophagus Sixteen tumors were associated with Barrett's epithelium in the esophagus. Fifteen of these were adenocarcinomas and one was a squamous cell carcinoma. The operative mortality rate for these patients was higher (25%) than for adenocarcinoma group as a whole
The Journal of Thoracic and Cardiovascular
6 6 Hennessy and Keeling
100
% 80
Surgery
I
~r
t ...
ADEND SQUAMOUS . - .
: I ~.
60
40
1- _e
L.-.
:- - .!
~.
1_-
~
I
20
.
I
I
,- - - - - - !l-:--_-_-_----_: -::_--:_:--::"-=--=-
OL.L...."=-l..-.---I 1
.L--_ _....r._ _- - - I
-J-
3
2
4
5
YEARS
Fig. 1. Life-table analysis showing survival in patients with adenocarcinoma and squamous carcinoma.
(19.4%) and the prognosis was worse, with a mean survival time of 9 months. Operative technique The Lewis-Tanner two-stage technique was used for the majority of middle-third tumors. McKeown's threephase technique" was used for the higher middle-third tumors. Lower-third tumors were resected by the LewisTanner technique, but some were approached through separate midline epigastric and left thoracotomy incisions. The majority of tumors of the cardia were resected by the latter approach with antroesophageal anastomosis. For tumors with extensive gastric involvement the entire stomach was included in the resection. Pyloroplasty was not performed unless narrowing of the gastric outlet was noted. All anastomoses were made by hand and staplers were not employed. Results Mortality. The operative mortality rate for all patients in the adenocarcinoma group undergoing resection was 19.4% (Table I). If the 16 patients with Barrett's esophagus are excluded, the mortality rate in the remaining 92 patients with adenocarcinoma was 18.4%. The overall mortality rate for all patients with squamous cell tumor undergoing resection was 14.4%. For patients with a middle-third squamous cell tumor the mortality rate was 16.3%, and for those with a lower-third tumor, 12.7%. The individual cause of death
is given in Table II for both groups. There were six deaths from anastomotic leak, three in the adenocarcinoma group and three in the squamous cell group. Both groups had a high incidence of postoperative myocardial infarction, which was the most frequent cause of death. The incidence of fatal postoperative chest infection was also similar in the two groups. A greater number of deaths caused by cardiac arrhythmia, sepsis, and cachexia occurred in the adenocarcinoma group. Age was an important factor in the operative mortality in both groups. Nine of 34 patients over 70 years of age with adenocarcinoma died (26.4%). Of the 74 patients with adenocarcinoma under 70 years of age, 12 died postoperatively (16%). Thirty-five patients over 70 years old had squamous cell carcinoma, of whom eight died (22.8%). In the under 70 group, seven of 69 patients with squamous cell tumors died (10.1%). Improved intensive care facilities, better anesthetic techniques, and increasing experience had a significant effect on the mortality figures in the latter part of the series. During the period 1971 to 1978, a total of 27 adenocarcinomas and 35 squamous cell carcinomas were resected, for mortality rates of 25.9% and 20%, respectively. From 1979 to 1985, a total of 150 patients underwent resection; 81 had adenocarcinomas and 69 had squamous cell tumors. During this period the mortality rate for adenocarcinomas fell to 17.2%and the mortality rate for squamous cell tumors dropped to 11.5%.
Volume 94 Number 1 July 1987
Morbidity. Postoperative complications are shown in Table III. Nonfatal anastomotic leaks occurred in three patients. All closed with conservative management and reexploration was not required. Some degree of stenosis necessitating dilatation developed at the anastomosis in 18 patients. In two of these patients, dilatation proved inadequate and the anastomosis had to be restructured. Pyloroplasty for persistent gastric stasis was necessary in three patients. Local recurrence developed in 12 patients, eight of whom were in the adenocarcinoma group. Two were treated by colon bypass, two by radiotherapy, and the remainder by intubation or intermittent dilatation. Survival Actuarial survival data are presented in Fig. 1. The 1 year survival rate in the adenocarcinoma group was 52.3% and in the squamous cell carcinoma group, 59.1 %. The 5 year survival rate in the adenocarcinoma group was 18% and in the squamous cell group, 18.7%. All 5 year survivors had Stage I tumors except for one patient with a Stage III squamous cell carcinoma. Discussion In this series of patients, adenocarcinoma of the esophagus and cardia presented with the same frequency as squamous cell carcinoma of the esophagus. The ratio of men to women, however, was twice that of the squamous cell group. The mean age of the two groups was the same and the duration of symptoms in both groups was similar. Nevertheless, the adenocarcinomas included a higher percentage of Stage III tumors. This would seem to suggest that dysphagia is a later manifestation in adenocarcinoma than in squamous cell carcinoma. Mortality statistics include all hospital deaths up to 3 months. The overall mortality rate of 17% contrasts unfavorably with such recently reported series as those of Ellis, 13 Akiyama," and their associates, whose mortality rates were 1.3% and 1.4%, respectively. However, Ellis, Gibb, and Watkins" have rightly pointed out that comparisons of the surgical results from different institutions may not always be valid, because of the different populations involved. Mortality rates of a similar order to this series (21%) have been reported by Van Andel, Dees, and Dijkhins." The high resectability rate as a consequence of our aggressive bias toward resection and the heavy mortality in the early part of these series account in part for the high overall mortality rate. The prevalence of chronic respiratory problems and cardiovascular disease in our general patient population is an additional contributory factor. The inclusion of all
Adenocarcinoma of esophagus and cardia
67
hospital deaths up to 3 months inevitably tends to produce higher mortality figures than the conventional 30 day mortality frequently employed. The 1 year survival rate in the adenocarcinoma group was not as good as in the squamous group, but the difference was largely due to the higher operative mortality in the adenocarcinoma group. The 5 year survival rates in both groups depended on the tumor stage. When the tumor was small and lymph nodes were not involved, 5 year survival was achieved by patients with adenocarcinomas and lower-third squamous tumors. Squamous cell tumors of the middle third had a particularly bad prognosis. This prognosis might have been improved had more three-phase procedures been performed. The results suggest that there is no inherent biological aggressiveness in adenocarcinomas and that the poor survival rate usually attributed to the tumors is simply a reflection of late diagnosis. Because of the lack of any worthwhile alternative to operation in treating adenocarcinomas, it is important to realize that despite their late presentation a small number of these patients are potential long-term survivors. REFERENCES I. Miller C. Carcinoma of the thoracic oesophagus and
cardia. Br J Surg 1962;49:507-22. 2. Ellis FH Jr, Maggs PRo Surgery for carcinoma of the lower oesophagus and cardia. World J Surg 1981;5:52733. 3. Skinner DB. Esophageal malignancies: experience with 110 cases. Surg Clin North Am 1976;65:137-47. 4. Griffith JL, Davis JT. A twenty year experience with surgical management of carcinoma of the esophagus and gastric cardia. J THORAC CARDIOVASC SURG 1980;79:44752. 5. Giuli R, Lortat-Jacob JL. Long term results in surgical treatment of oesophageal carcinoma. In: Silber W, ed. Carcinoma of the oesophagus. Rotterdam, Capetown: Balkema, 1978:390-412. 6. Webb IN, Busuttil A. Adenocarcinomaof the oesophagus and of the oesophago-gastric junction. Br J Surg 1978; 65:475-9. 7. Gunlaugsson GH, Wychulis AR, Roland C, Ellis FH. Analysisof the recordsof 1657 patients with carcinoma of the oesophagus and cardia of the stomach. Surg Gynecol Obstet 1970;130:997-1006. 8. McKeown KC. Carcinoma of the oesophagus. J R Coll Surg Edin 1979;24:253-74. 9. Earlam R, Cunha-Melo JR. Oesophageal squamous cell carcinoma: a critical review of surgery. Br J Surg 1980; 67:381-90. 10. Lortat-Jacob JL, Maillard IN, Richard CA, Fekete F, Lanois B. Surgical treatment of cancer of the oesophagus. Br J Clin Pract 1970;24: 13-8.
68
Hennessy and Keeling
11. Stone R, Rangel OM, Gordon HE, Wilson SE. Carcinoma of the gastroesophageal junction. Am J Surg 1977;134:70-6. 12. McKeown KC. Total three-stage oesophagectomy for cancer of the oesophagus. Br J Surg 1976;63:259-62. 13. Ellis FH Jr, Gibb SP, Watkins E Jr. Esophagogastrectomy: a safe, widely applicable and expeditious form of palliation for patients with carcinoma of the esophagus and cardia. Ann Surg 1983;198:531-9.
The Journal of Thoracic and Cardiovascular Surgery
14. Akiyama H, Tsurumaru M, Kawanura T, Ono y. Principles of surgical treatment for carcinoma of the esophagus: analysis of lymph node involvement. Ann Surg 1981; 194:438-46. 15. Van Andel JG, Dees J, Oijkhins CM. Carcinoma of the esophagus: results of treatment. Ann Surg 1979;190: 684-9.
Bound volumes available to subscribers Bound volumes of THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY are available to subscribers (only) for the 1987 issues from the Publisher, at a cost of $49.00 ($66.00 international) for Vol. 93 (January-June) and Vol. 94 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue of the volume. The binding is durable buckram with the JOURNAL name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact The C. V. Mosby Company, Circulation Department, 11830 Westline Industrial Drive, St. Louis, Missouri 63146, USA; phone (800) 325-4177, ext. 351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular JOURNAL subscription.