Carcinoma of the esophagus

REVIEW

Carcinoma

of the Esophagus

A Twenty Year Study LEWIS W. PINCH, M.D., KJELL

H. CHRISTIANSEN, M.D., AND WILLIAM

C. STAINBACK, M.D.,

Bryn Mawr, Pennsylvania

From the Department of Surgery, Bryn Mawr Hospital, Bryn Mawr, Pennsylvania.

HE LONG-TERM SURVIVAL for

T carcinoma

TABLEI SYMPTOMSOFESOPHAGEALCARCINOMA

esophageal

has been discouraging. The diagnosis is usually made late in the course of the disease and thus the treatment has been ineffectual. Nestled deep within the mediastinum, with an abundant vascular and lymphatic system, the esophagus has evaded the two most effective curative treatments known for carsurgery and radiotherapy. cinoma, namely, Fortunately, the incidence is reported to be on the decrease. Presented here is a twenty year survey of carcinoma of the esophagus in a community general hospital. Our experience again points out uniformly poor results of treatment. We will briefly explain why this is and comment on the possibility of improving results.

Symptom

No. of Patients

Duration of Symptoms (mo.)

No. of Patients

Dysphagia Weight loss Chest pain Hoarseness Weakness

51 44 24 11 55

1 or less l-3 3-6 More than 6 Unknown

9 7 18 17 6

pointed out this high incidence of carcinoma of the esophagus in low income groups and Negroes. The average age of incidence was sixty-eight years with two occurrences between the ages of forty and forty-nine, eight between the ages of fifty and fiftynine, twenty-two between the ages of sixty and sixty-nine, eighteen between the ages of seventy and seventy-nine, and seven between the ages of eighty and eighty-nine. There were forty-six male patients and eleven female patients. The male to female ratio of four to one agrees with most other studies [f-3]. The chief complaint was dysphagia in 90 per cent of patients, and almost all complained of weakness. (Table I.) An interesting observation is the paucity of patients with bleeding as a symptom, whereas in all other parts of the gastrointestinal tract bleeding or anemia due to bleeding is a prominent finding. As others have noted, the duration of the symptoms is usually three months or more and often six months and longer. (Table I.) A positive diagnosis was made by barium swallow in 74 per cent of the patients and a diagnosis with suggestive evidence of carcinoma in an additional 22 per cent of the patients. (Table II.) Esophagoscopy was diagnostic in 94 per cent of the forty-one

CLINICAL MATERIAL Fifty-seven patients were diagnosed as having cancer of the esophagus at The Bryn Mawr Hospital in the twenty year period from 194.5 to 1964 inclusive. A careful attempt was made to select only those patients who had esophageal cancer, excluding the adenocarcinomas that arose from the cardia of the stomach. Thirty patients were treated by their private physicians while twenty seven were treated on the ward. Approximately 90 per cent of all patients admitted to this hospital are private patients which indicates a high incidence of patients with esophageal carcinoma in the lower income group. Parker, Gregorie, and Hughes [I] and Kay [2] have also io4

American

Journal

of Surgery

705

Carcinoma of Esophagus TABLE

TABLE III

II AVERAGE

DIAGNOSIS IS ESOPHAGEAL CARCINOMA

SURVIVAL

OF PATIENTS

WITH

ESOPHAGEAL

CARCINOMA --Diagnosis----

NO.

Diagnostic

of Patients

Procedure

Esophagoscopy Barium swallow

41

Bronchoscopy

19

Ques-

39W%‘,)

2 (6%)

9

(26%)

50 “;;;;F;

0

Therapy

Negative

tionable

Positive

;

1(4%‘,)

None X-ray

19 19 1 12

treatment

13 (67%) Resection*

2 patients

who

was performed

had

esophagoscopy.

in nineteen

Bronchoscopy

of the fifty-seven

patients

and

in four there was a tracheoesophageal fistula. Two patients were diagnosed at autopsy and the remaining five had a positive diagnosis made at another hospital. The pathologic type was squamous cell carcinoma in forty-four patients, adenocarcinoma in three, and anaplastic carcinoma in two; no specimen was taken in two patients. Of the two anaplastic lesions one was believed to be a sarcoma. Fifteen lesions were in the upper third of the esophagus, twenty-six in the middle third, and sixteen in the lower third. These figures are also in agreement with most other statistics on location [f-5]. TREATMENT

AND

RESULTS

It can be seen that essentially there was (1) x-ray therapy, (2) esophageal resection, or (3) no treatment. Although a gastrostomy was performed in thirteen patients, it was not considered to be a primary means of treatment since it does not affect the progress of the disease [6]. There were nineteen patients who had no treatment, twenty patients who had external irradiation, and fourteen patients who had esophagogastrectomy. Two patients had resec-

I Week

I -

3

6

9 12 MONTHS

FIG. 1. Graphic representation esophageal carcinoma occurring period. Vol. 111, Muy 1966

-

15

I8

21

of survival rates for during a twenty year

Resection

and s-ray

* Of the patients six months.

treatment with resection,

2

2 5.7 T years 3 6 Unknown 11

six survived

beyond

tion combined with x-ray therapy and in two patients the lesion was found at autopsy. The survival rates for the three methods of treatment are seen in Figure 1. There were no survivors beyond fifteen months for the untreated patients and those with resection. There was only one survivor beyond twentyone months with x-ray treatment alone. The two patients who had both resection and x-ray therapy survived for eight months and twenty months. The operative mortality for the group treated by esophagogastrectomy was found to be 50 per cent. The average survival with the three basic treatments is seen in Table III. COMMENTS

The incidence by age and sex, duration of symptoms, type of symptom, and method of diagnosis confirm the findings of other surveys on this subject [1-J,&?]. The location of the lesions and their histologic types tend to support the fact that cancer of only esophageal origin was included in this study. It is sometimes difficult to determine the origin of the lesion but if there was any question that the lesion might have originated in the stomach, the case was not included in this study. This distinction may be important in the final analysis of the results of treatment. Ellis [8] and Sweet and Terracol [Y] presented excellent results in the treatment of cancer of the esophagus and cardia. They included gastric lesions and thus had a much higher incidence of adenocarcinomas and a greater incidence of resections for lesions in the lower third of the esophagus. This may improve the over-all mortality and survival rates, since lower operative mortality

706

Pinch, Christiansen,

and higher survival rates can be expected with resection of the lower third of the esophagus. The diagnosis of carcinoma of the esophagus was made in many patients in this series at a late or terminal stage of the disease. Two facts confirm this: first, most patients had their symptoms three months or longer prior to treatment; and second, most patients received no treatment or palliative x-ray therapy only. The best chance for cure for carcinoma in general is early and adequate removal. In esophageal cancer neither early nor adequate removal of the tumor can be accomplished in most cases. The majority of patients are elderly and when first seen they are depleted nutritionally. All too frequently at thoracotomy massive mediastinal involvement precludes excisional therapy. The submucosal extension is often so extensive that only a total esophagectomy could accomplish adequate removal of the lesion in the esophagus. The presence of tracheoesophageal fistulas and distant metastases preclude surgery for cure. The high operative mortality of 50 per cent in the sixteen patients who underwent esophagogastrectomy is attributed to several factors including small case loads, the advanced age of the patients, the extensiveness of the surgery, poor nutrition, and perhaps poor preoperative selection of patients. Others [2,3,5,6], however, have also reported an overall operative mortality of 38 to 50 per cent. In almost all studies, the operative mortality for resection of the upper two thirds of the esophagus varies from 30 to 60 per cent. One of the lesions in our series was a polypoid lesion in the upper esophagus and histologically was interpreted as a sarcoma. This patient was given x-ray therapy only and is the longest survivor of the group, having died of carcinoma of the lung seven years after the esophageal sarcoma was first treated. Camishion, Templeton, and Gibbon [IO] in a recent review of the subject believe that sarcomas of the esophagus have a better prognosis than carcinoma. Moore and co-workers [ll] and Young and Gardner [12] have reported groups of patients with poIypoid carcinosarcoma which after treatment have shown a better average survival than those with carcinoma of the esophagus. It is our belief, based on these findings and the impression of others [7,13-151, that x-ray therapy should be used in all cases, either alone or in combination with resection. In the upper

and Stainback third of the esophagus perhaps x-ray therapy alone is warranted. In carcinoma of the lower two thirds of the esophagus a very careful attempt should be made to select only the best patients for resection and to combine this with x-ray therapy. Palliative resection carries too high a mortality rate to warrant its use. These patients should instead receive only x-ray therapy. SUMMARY

A survey of fifty-seven patients with cancer of the esophagus occurring over a twenty year period is presented. The presenting complaints of the disease, methods of diagnosis, and characteristics of the disease are discussed. Three equal treatment groups consisting of no treatment, x-ray treatment, and surgical resection were compared and the results were extremely poor. Only one patient in all three groups survived longer than two years. It was our conclusion, supported by the opinion of others, that x-ray therapy gave the best palliation in most cases and that surgical resection for cure should be used in only the most suitable patients. REFERENCES

1. PARKER, E. F., GREGORIE, H. B., and HUGHES, J. B. Carcinoma of the esophagus. Ann. Surg., 153: 957, 1961. 2. KAY, S. A ten year appraisal of the treatment of squamous cell carcinoma of the esophagus. Surg. Gynec. & Obst., 117: 167, 1963. 3. FRANKLIN, R. H., BURN, J. I., and LYNCH, G. Carcinoma of the oesophagus. Brit. J. Surg., 51: 78, 1964. 4. ONG, G. B. Surgical treatment of esophageal carcinoma: personal experience of 112 cases. Brit. J. Surg., 51: 53, 1964. 5. RICHARDS, C. A. Treatment of cancer of the esophagus. Uzoraxchirzrrgie, 11: 44, 1963. 6. KILLEN, S. A., EDWARDS, W. H., and DANIEL, R. A. Carcinoma of the esophagus. J. Thoracic 6 Cardiovas. Sltrg., 48: 491, 1964. 7. ANABTAWI, I. N., BRACKNEY, E. L., and ELLISON, R. G. Carcinoma of the esophagus treated by combined radiation and surgery. J. 7%oracic 6” Cardiovas. Suvg., 48: 205, 1964. 8. ELLIS, F. H. Treatment of carcinomas of the esophagus and cardia. Proc. Stuff Meet. Mayo Clin., 35: 635, 1960. 9. SWEET, R. H. and TERRACOL, J. Diseases of the Esophagus. Philadelphia, 1958. W. B. Saunders co. 10. CAMISHION, R. C., TEMPLETON, J. Y., III, and GIBBON, J. H. JR. Leiomyosarcoma of the esophagus. Report of two cases and review of the literature. Ann. Swg., 153: 951, 1961. 11. MOORE, T. C., BATTERSBY, J. S., VELLIOS, F., and Am&can

Journal of Surw’y

Carcinoma LOCKS, W. 11. Carcinosarcoma of the esophagus. J. Thoracic- b Cardiovas. Surg., 45: 281, 1963. 12. YOUNG, B. and GARDSER, D. C. Polypoidal carcinosarcoma of the oesophagus. Bvit. J. Surg., 51: 584, 1964. 13. GORDON, M'. Choice of treatment in cancer of the thoracic esophagus. ,&‘e~ York J. Need., 63: 3384, 1963.

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14. SLOVER, W. I’. Epidermoid carcinoma of the esophagus: experience with radiotherapy at Hartford Hospital 1946 through 1961. Hartford Hosp. Bull., 18: 732, 1963. 15. WALKER, J. H. Carcinoma of the esophagus-cobalt 60 teletherapy; experience and comparison with surgical results. Am. .T. Rorntgenol. 92: 6;. 1963.