Carcinoma of the esophagus

Carcinoma WILLIAM L. WATSON, From the Tboracic Cancer and Allied

Surgical Diseases,

M.D.

of the Esophagus AND

JOHN T. GOODNER, M.D., New York, New York

Service, Memorial Center for New York, New York.

various methods of treatment have been unjustifiably optimistic. A carefu1 study of the clinica course of the disease, the anatomy of the organ and the postmortem material availabte will show that when cancer of the esophagus is first diagnosed the patients are usuaIIy in a stage in which their disease is not curable by any of the methods of treatment available at the present time. Therefore, in most cases of esophagea1 cancer the treatment of choice should be directed toward paIIiative management. The material for this report has been taken from the records of Memorial Hospital accumulated during two periods of our experience. The first series was accumulated between 1918 and 1931. Five hundred six patients with carcinoma of the esophagus were admitted to the hospital during that interva1. The second group of patients was admitted to Memorial Hospital between 1931 and 1955; a total of 1,250 patients were admitted during this interval. Therefore, the tota number of patients with cancer of the esophagus suitabIe for study is 1,756. The origina group of 506 patients has previously been reported [I I]. It must be noted that this materia1 consists of a11 patients who come to MemoriaI HospitaI with cancer of the esophagus regardIess of the stage of their disease. Almost all of our patients are in the advanced stage of the disease; a high percentage are in a hopelessly advanced stage and are even moribund at the time of admission. Many of the patients have undergone surgica1 and radiation therapy at other institutions before coming to us. The high mortality rate and the low saIvage rate for this disease is well known, and when the material is so heavily weighted with hopetess cases the study of it naturatly paints a very gIoomy picture.

ANCER of the esophagus has engaged the serious attention of many capable surgeons, pathologists, endoscopists and internists during the past haIf century. The radiation therapist is concerned with this disease and has added to the widespread interest of the medical profession, and considerabIe literature on this subject has accumulated. Much original thought, experimentation and imagination has gone into the development of the many and varied forms of treatment which have been advocated at one time or another for the cure of cancer of the esophagus. Noteworthy among these methods was the advent of radium as an intraesophagea1 method of radiation. This form of treatment was first proposed in 1904 and soon afterward the Iiterature was II ooded with descriptions of many new types of apparatus, new dosages, new filters and new methods for accurately locating the radium in the esophagus. This period which began so hopefuIIy was not, however, foIlowed by reports of cures or even good palliative results and the method soon feI1 into disfavor. A great deal of attention has been directed toward the development of a procedure for the radical, surgica1 removal of carcinoma of the esophagus. History records that the first successful, intrathoracic esophagectomy was accomplished in this country by Torek in 1913 [7]. With this demonstration that the esophagus could successfully be removed and that a patient with cancer of that organ couId be cured, it was natural to suppose that the management of esophageal cancer by means of surgery wouIc1 be just a matter of technical skill, and surgery was thought to have reached a point where it couId be caIIed an answer to the problem of esophagea1 cancer. Unfortunately, surgery has not fu1fiIIed its early promise. Such a general Iack of success would Iead one to suspect that those who have advocated the

C

ETIOLOGY It is, of course, impossible etiologic data regarding cancer

259

to give exact of the esopha-

Watson

and Goodner

gus. However, it is now quite generahy beIieved that there are certain definite factors predisposing to esophagea1 cancer. In the oraI cavity it has been shown that broken, irregular or sharpIy worn teeth, iII-htting dentures, IeukopIakia, excessive pipe smoking, syphilis and 30-

277

20%

21.3 14.9 11.9

IO-

FIG.

I. RaciaI distribution of cases in percentages.

intraora1 sepsis are definiteIy irritating factors and in some cases at Ieast exert a carcinogenic action in the causation of intraora1 cancer. Similar factors prepare the esophagea1 mucous membrane for precancerous changes. BadIy kept teeth, intraora1 sepsis and iII-fitting plates tend to cause hasty and incompIete mastication which makes it necessary for the esophagus to handIe masses of food which are often too Iarge and too hard. Such a Iarge, hard food boIus causes a certain amount of trauma and inffammation of the esophagea1 mucous membrane. The passage downward of such a boIus wouId be sIowest at the points of anatomic constriction and resuIting trauma is greatest, therefore, at these points. The trauma causes irritation which Ieads to spasm and with it further sIowing of the food boIus and Iater even stagnation, esophagitis, uIceration and possibIy neopIasm. ThermaI irritation is probabIy the most constant factor predisposing to carcinoma of the esophagus. The frequent drinking of copious amounts of excessiveIy hot tea is a history frequentIy obtained from the Russian patient with cancer of the esophagus. This fact is especiaIIy significant when it is noted that 46 per cent of the foreign-born patients in our first series were born in Russia. There were more.: Russians than native Americans. In China, cancer of the esophagus is very uncom260

mon among the women and this is said to be due to the fact that they eat after the men have finished and their rice is not as hot. The women of Scotland drink excessively hot tea and Turner [8] has reported that cancer of the esophagus is more common in them than it is among the men. (Fig. I.) LeukopIakia of the esophagus is being recognized more frequentIy due to the increasing popuIarity of the esophagoscope. We have found it to be a common condition and it has been reported to have been present in 60 per cent of 200 non-cancerous cases autopsied. CIinicaIIy and pathoIogicaIIy, the process is the same as that seen in the ora cavity where it is dehniteIy a precancerous condition [6]. Others who have had extensive experience with esophageal cancer think that the excessive use of aIcoho1, spiced food and tobacco are factors in many cases. Others have reported that cancer of the esophagus is often definiteIy attributed by the patient to some particular menta1 or physica shock. It has been observed that there was an increase in the incidence of cancer of the esophagus in young aduIts foIIowing World War I. It was thought that the foIlowing sequence of events had taken pIace: first an emotiona upset, then esophagea1 spasm and IinaIIy stasis Ieading to esophagitis stricture and hnaIIy cancer. Jackson [J] says that cancer of the esophagus occurs in patients who have had esophagea1 spasm for years. Mosher [y] demonstrated the presence of thin webs and pouches in the esophagus and these were thought to have some etioIogic bearing as the cicatricia1 contractures which resuIt from the swaIIowing of caustic soIutions or resuIt from the heaIing of peptic or traumatic uIcers. In one of the youngest maIe patients in our series, cancer of the esophagus developed in a cicatricia1 scar resulting from the ingestion of Iye when he was three years old. He was twentyeight when cancer of the esophagus appeared. SyphiIis does not pIay an important role in the etiology of esophageal cancer and in our series it was present in about the same proportion as it is in the genera1 population. INCIDENCE

SIightIy more than 2.5 per cent of a11 the patients admitted to MemoriaI HospitaI with maIignant disease have cancer of the esophagus. In New York City, where more than 8,000 cancer deaths occur each year, it has

of Esophagus

Carcinoma been shown that about 280 of these are due to cancer of the esophagus, an incidence of about 3.5 per cent. In England cancer of the esophagus is said to comprise about 5 per cent of a11 cancer deaths, and others have reported an incidence of as high as IO per cent.

series almost two-thirds of the patients gave as their first symptom,diffIculty in swallowing solid foods. If the mortality from this disease is to be reduced, earIier diagnoses must be made and earlier symptoms must be sought for and detected. When dysphagia, dehydra600

SEX

is well known that this disease is much more common in the male than in the female. Guisez [2], in reporting 1,430 cases, found the ratio to be six maIes to one female. Jackson [5] with 671 cases, reported an 87 per cent incidence in males. In our second series of 1,250 patients, there were I,OI I males and 239 females, or a ratio of four mates to one female. It

500

m

MEN WOMEN 0 I 16 5 137 34 394 94 463 95 194 41 22 2

WOMEN

400 300 200 100

AGE

0

The greatest number of patients, both maIe and female, were between the ages of sixty and sixty-nine. In eleven of twelve patients cancer developed between the ages of fifty and seventy-nine. It is interesting to note that we have had twenty-two maIe patients and two female patients in whom cancer of the esophagus deveIoped after the age of eighty. Our figures also seem to indicate that in women cancer of the esophagus deveIops at a slightly earlier age than in males. (Fig. 2.)

20

40

FIG. 2. Distribution

treatment,

so

00

of ages of patients admitted men and women compared.

for

tion and emaciation exist, the disease is almost always hopelessly advanced and incurable. Dysphagia alone is not an infallible diagnostic symptom of esophageal cancer as it may occasiona1Iy be entirely absent even in patients dying of the disease, and in other cases it may have been present for twenty years or more as a result of so-caIIed cardiospasm. Dysphagia is thus an unreliabIe symptom and of IittIe aid in making an early diagnosis. Under early symptoms we have occasionally noted vague complaints such as a feeling of substerna pressure, a feeling of obstruction, hiccoughs, hoarseness, difhculty in breathing, heartburn and increased mucus. Foul breath is a common symptom. Pain is not an earIy symptom and when backache, substerna discomfort or pain do exist it foIlows that the disease has extended beyond the esophageal walls into the posterior mediastinum. Hoarseness, when present, is usually due to invoIvement of the recurrent IaryngeaI nerve and is most commonly noted on the left side. Regurgitation, vomiting, loss of weight, weakness and pain are al1 symptoms of a Iate stage of the disease. In making our pIea for earher diagnosis it is we11 to recognize that the earIy symptomatoIogy is often too vague to be of much help in this direction. We undertook a study of well patients in which we took an esophagram of every person over the

SYMPTOMATOLOGY The onset of carcinoma of the esophagus is a most insidious one and although we have a ready means (esophagoscopy) for making a positive diagnosis, it is stiI1 a fact that one seldom sees a patient in the earIy stages of esophageal cancer. The function of the esophagus is to transport food from the pharynx to the stomach and this function is onIy seriously interfered with late in the course of the disease. Then, too, the patient tends to masticate his food more thoroughly after he first notices that large particIes of food have a tendency to stop or stick part way down the guIIet. Such periods of temporary dysphagia teII a story to the physician, but unfortunately the patient pays little heed to such a matter and will mention it onIy when a carefu1 history is obtained. When definite, persistent dysphagia occurs and the patient seeks reIief for it, his disease is usuaIly well advanced. It is most unfortunate that dysphagia should so often be the first symptom of esophagea1 cancer. In our 261

Watson

and Goodner

age of forty, hoping in this way to discover early cases of esophagea1 cancer. A very Iarge number of patients were studied in this manner and onIy one tumor of the esophagus was discovered; although this patient’s growth was resectabIe and she has remained we11 for eleven years, the investigation was considered to be too expensive, too time-consuming and therefore impractical.

peutic management of the patient whether this be by surgery or radiation. At the completion of the esophagoscopy the trachea and main bronchial tree is examined through the bronchoscope for evidence of possible direct extension of cancer from the esophagus. TREATMENT

The majority of our patients coming to MemoriaI Hospital with cancer of the esophagus are in the advanced stage of the disease and the question of surgical management of the cancer cannot seriousIy be considered. Radiation atone or in conjunction with supportive surgical measures such as gastrostomy has therefore been cahed upon to shouIder most of the responsibihty for the palliative management of these patients. ExternaI radiation, whether given by the conventional 250 k.v., the I m.e.v., or the 60 cobalt units, requires for best results a very carefuI and proper outlining of the treatment portaIs in order to cross fire the beam of radiation accurately in the thoracic cavity at the level of the cancer. These portals must be mapped out on the skin of the chest anteriorly and posteriorly under fluoroscopic control with the patient in the position in which he is to receive treatment. The upper and lower limits of the cancer are marked with lead strips both posteriorly and anteriorly. It is we11 known that cancer of the esophagus spreads longitudinally by way of the submucosa1 Iymphatics, and for this reason an area of tissue much greater than that shown on the roentgenograph or by endoscopic study must be included in the beam of radiation in order to obtain a satisfactory resuIt. Skin portals smaher than 14 by 7 cm. are therefore seldom used. We commonly employ four portals, two anterior and two posterior, leaving a free zone of 4 cm. in the midline anteriorIy and posteriorly to preserve that portion of skin from possible damage due to cross firing of the beam of radiation. We have employed intraesophageal radium therapy in a group of patients who have had prehminary gastrostomy. A 30 mg. radium eIement tandem applicator with a total fiItration equivalent to z mm. of brass has been found to have a most beneficia1 effect in reducing tumor infection, heahng ulceration and widening the lumen of the esophagus at the tumor site. In our hands it has, however, faiIed

DIAGNOSIS

Cabot [g], in his report on 3,000 autopsies, showed that the diagnosis of cancer of the esophagus couId be compIeteIy missed. In his series there were twenty cases of carcinoma of the esophagus; in four of these the diagnosis had not been made before death and in three it had been merely suspected. It must be emphasized that esophagoscopy is absolutely necessary for an early and accurate diagnosis of esophageal cancer. Complicated apparatus, difficuh x-ray technics and various opaque mixtures have been deveIoped so that an early ro’entgenographic diagnosis is possibIe, but these have Iost their popularity to some extent due to the more satisfactory esophagoscopic results. The folIowing diagnostic procedures are carried out at MemoriaI HospitaI, during the investigation of a patient suspected of having carcinoma of the esophagus. FolIowing the usua1 history and general physica exnmination the patient is given a more detailed examination of the head and neck, oral cavity, larynx and the like, and bIood is taken for a Wassermann test and liver studies. Following this he is sent for fluoroscopy and barium swalIowing, and then x-ray fiIms are taken of the esophagus and lungs. The following day the patient is taken to the endoscopic room; the pharynx is cocainized, esophagoscopy is performed and a biopsy specimen obtained. Fluoroscopy is essential for a complete examination because by this means we are abIe to observe the function of the esophagus. The procedure also determines the following points regarding cancer in this organ: size, shape, outIine and position of Iesion, as we11 as the size and shape of the lumen above and beIow the obstruction. This information is of the utmost value in determining what form of treatment should be instituted. We believe that the endoscopic procedures should be performed-by the surgeon who is to direct the future thera-

262

Carcinoma

af Esophagus

to

is deepIy situated and intimately surrounded by important and vital structures which are often invaded early in the natura1 course of the disease. In the thoracic esophagus ulcerating, badly infected cancers are apt to develop which

eradicate the cancer completely in an) individua1 case. Radon in the form of goId-CItered seeds has been used frequentIy. The seeds are inserted at periodic intervals by means of the esophagoscope. For the most part, these gold-filtered radon seeds in adequate dosage have a remarkable tendency to melt down the cancer within a zone of I cm. of their site of application, but here again the results have not been satisfactory because intensive radiation produces excessive tumor sloughing and this in turn is often followed by perforation of the esophagus and fatal mediastinitis. An additiona technical difIicuIty is the accurate pIacement of the goIdfiItered radon seeds in the dista1 portion of the tumor through the esophagoscope. (Table I.) SURGERY

FOR

CANCER

OF

THE

TABLE L METHODOF TREATIMENT 1N CASES OF

ESOPHAGUS

OF

CANCER

(1918-1955)

Average Length of Life after Admission (mo.)

Treatment

ESOPHAGUS

External radiation only: Moderate. Inadequate. Intraesophageal radiation only: Radium in capsules. Radon seeds. ExternaI plus intraesophageal mdiation : Radium in capsules. Radium in capsules and radon seeds Radon seeds. Gastrostomy only*. Esophagogastrostomy (by-pass) only. Gastrostomy pIus external radiation. Esophagogastrostomy (by-pass) plus externa1 radiation. Gastrostomy plus intraesophageal radiation: Radium in capsuIes. Radon seeds. Gastrostomy pIus externa1 and intraesophageal radiation : Radium in capsuIes. Radium in capsules and radon seeds Radon seeds. . Resection only. Resection and externat radiation. No treatment.

Most surgeons agree that a satisfactory discussion of surgical measures for the treatment of cancer of the esophagus shouId be divided into three parts based on the anatomy of the organ under consideration. It seems quite clear that the cervica1 esophagus, the mid-thoracic esophagus and the abdominal portion of the esophagus vary so greatIy in their structure, location and curabiIity that they need to be discussed as separate surgical probIems. Cancer of the Cervical Esopbagus. We have had I I 5 such cases and there have been seventyfive operations. It seems clear that eradication of the cancer in the cervica1 esophagus requires radica1 measures and our patients are therefore treated by combining a uniIatera1, radica1 neck dissection with complete thyroidectomy and IaryngocervicaI esophagectomy. It has aIso been found that remova of the first portion of the sternum makes for an easier excision of the neck tissues and at the same time permits a limited dissection of the superior mediastinum. Nineteen of these patients who underwent excisional surgery have survived Iong enough to permit reconstruction of the esophagus by pIastic procedures [g]. An additiona four patients with cancer of the cervical esophagus underwent tota esophagectomy with anastomosis in the neck performed between the stomach and the hypopharynx. Cancer of the Mid-thoracic Esophagus. From the surgica1 point of view it is obvious that cancer of the thoracic esophagus wiI1 prove to be diffIcuIt to manage and the salvage rate will be low. This is because the thoracic esophagus

I 239 30

6.2

3.3 4. 5.75

12

3

4.3 6. 10.8 ’30 3 404

35

1.5 7.6

4.3 8.5

24

27 3 ‘7

5.7 10.2

18.8 II.3

126

20 5 3 1

56 95 1

,

* Patients treated only by gastrostomy were those whose general condition was too poor to permit palliative radiation.

metastasize readiIy by way of the rich submucosa1 Iymph vesseIs into the adjacent mediastina1 lymph nodes. It is important to note that these same intramural lymphatic vessels aIso distribute the neoplastic cells in a longitudinal direction, often to a considerable distance above and beIow the visibIe and palpabIe Iimits of the primary cancer. ViabIe tumor 263

Watson and Goodner Servical Lykph Nodes

Ifi%.

Bones 8% Aorta S%r

./”

t z. Mediastinol I LvmPhNodes

1 Maocitric PC LymphNodes

II% Liver 20%

-

FIG. 3. Diagrammatic sketch the various organs and Iymph

illustrating

the

reIative

frequency

with

which

node areas are invoIved in secondary deposits from carcinoma of the esophagus. The diagram is based on 181; postmortem

emboh may bIock a Iymphatic branch and give rise to a secondary deposit of cancer appearing as a submucosal outcropping sometimes as much as 8 cm. distant from the primary cancer. (Fig. 3.1 An earIy review

END RESULTS

of esophagea1

TABLE II IN CASES OF ESOPHAGEAL

(1,250 FIVE-YEAR

of our cases

CASES,

SURVIVAL

AFTER

TREATMENT

Location of Cancer

Treatment

_

Surgeryalone. Radiation

alone.

Combination of SWgery snd radiation Total five-year vivals. *Two

CANCEK

1931-195’)

~

--

77

3

4

CervicaI esophagus. I Distal esophagus. z

929

6

0.65

Cervical

ekphagus, 3

Uooer thoracic. I I&b-thoracic, ; Lower esophagus, I Cervical esophagus. 2 Mid-thoracic. I

sur-

hundred five cases lost to folIow-up.

264

resection indicated a higher incidence of inadequate IongitudinaI excision than we had anticipated. Seventy-nine cases were analyzed and 45 per cent of the patients with esophageal cancer who were subjected to segmenta resection had an inadequate IongitudinaI remova of their disease. SurgicaI faiIure was estabIished on a critica microscopic basis. In the hope of cutting down the Iocal recurrence rate and possibly increasing the cure rate, it was apparent in dealing with intrathoracic esophagea1 cancer that a Ionger portion of the organ needed to be removed. Therefore, it was decided to perform a series of Torek type esophagectomies. Forty-eight tota esophagectomies for cancer were performed; thirty-one of our forty-eight patients who underwent tota esophagectomy for cancer survived Iong enough to permit esophagopIasty. In the Iast seven tota esophagopIasties we have empIoyed right colon retrosternal transpIants. This operation is not a new idea as it was first reported in 1911 by KeIIing [4]. The surgical technic and our resuIts have been

Carcinoma

of Esophagus of the stomach, secondaril,v invading the termina1 esophagus, have not been included in our statistics. Such patients, when managed surgically, have a fair prognosis with an improved salvage rate. For these reasons a surgeon may be tempted to include them with other cases of esophagea1 cancer and so improve his over-all five-year survival figures.

pubIished [lo]. It is our present opinion that when the thoracic esophagus is the site of cancer, complete esophagectomy is indicated whenever feasible and the most satisfactory method for reconstruction of the intestinal tract is a right colon substerna complete esophagoptasty. Cancer of the Cardiac and Abdominal Portion In this region the prognosis of the Esophagus.

is better than for any other segment of the esophagus. Here too the surgeon is permitted to perform a more radica1 operation with lymph node dissection, and the immediate reconstruction of the excised segment of esophagus can readily be accompIished using the stomach. (Table II.) END

RESULTS

IN

ESOPHAGEAL

REFERENCES

I. CABOT, R. C. Diagnostic pitfalls. Identified during a study of 3000 autopsies. J. A. M. A., z2952298, 1912. 2. GUISEZ, J. Early signs of cancer of the esophagus. Presse mkd., 34: 964-966, 1926. 3. JACKSON, C. Why does not the thoracic surgeon cure cancer of the esophagus? Arch. Surg., 12: 236-240, 1926. 4. KELLING, G. OseophagopIastik mit HiIfe des Querkolone. Zentrabl. f. Cbir., 38: I209 -1212, 191 I. 5. MOSHER, H. P. Stenosis of esophagus. Tr. Am. Laryngol., Rbinol., Otol., Sot., 20: I 79-200, 1914. 6. SHARP, G. S. Leukoplakia of the esophagus. Am. J. Cancer, 15: 2029-2043, 1931. 7. TOREK, F. The first successfu1 case of resection of the thoracic portion of the esophagus for carcinoma. Surg.: Gynec. TV Oh., 16: 614, IgI3. 8. TURNER. A. L. Carcinoma of the Dost-cricoid renion and upper end of the esophagus. J. Laryng. e* Otol., 35: 34, 1920. g. WATSON, W. L. and CONVERSE, J. M. Reconstruction of the cervica1 esophagus. Plastic v Reconstruct. Sutg., 2: 183-196, 1953. IO. WATSON, W. L., GOODNER, J. T., MILLER, T. P. and PACK, G. T. Torek esophagectomy. The case against segmentat resection for esophagea1 cancer. J. Tboracic Surg., 32: 347-359, 1956. of the esophagus. I I. WATSON, W. L., Carcinoma Surg., Gynec. &’f&t., 56: 884-897, 1933.

CANCER

In a series of 1,230 cases, including “all comers” regardless of condition of patient and stage of disease, there have been onIy tweIve survivak for five years or longer. Seventyseven patients were treated by surgery aIone and there have been three survivals, a 4 per cent five-year surviva1 rate. Nine hundred twenty-nine patients received onIy radiation and six have survived more than five years for a salvage rate of 0.65 per cent. Thirty-nine patients received both surgeq and radiation treatment, and there were three survivak, or 7.7 per cent. In six patients (50 per cent) in the group of five-year survivals, the cancer was Iocated in the cervica1 esophagus. The prognosis wouId appear to be more favorabIe in this anatomic area. It should be noted that patients with cancer

265