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Treatment and survival in cancer of the cervical esophagus
Treatment and Survival in Cancer of the Cervical Esophagus JOHN T. GOODNER,
This is a report on the treatment of cancer of the cervical esophagus during a period of over forty years extending from 1928 through 1968. During this period 1,904 cases of cancer of the esophagus were seen at Memorial Hospital. There were 1,706 cases of cancer of the thoracic esophagus and 198 cases of cancer of the cervical esophagus. Clinical
Data
Incidence. Of the 198 patients with cancer of the cervical esophagus 131 were male (66 per cent.) and 67 were female (34 per cent), a ratio of 2:l. In 260 cases of cancer of the thoracic esophagus treated surgically [I], the incidence of males to females was 77.4 and 22.6 per cent, a ratio of more than 3:l. Of the 198 cases of cancer of the cervical esophagus, the majority of patients fell in the fifty to fifty-nine and sixty to sixty-nine year age groups in both sexes. In the seventy to seventy-nine year age group there was a predominance of males over females. Pathology. Of the 198 cases, 173 (87 per cent) were squamous or epidermoid carcinomas. There were three cases of adenocarcinoma and one each of fibrosarcoma and mucoepidermoid carcinoma. Two cases were not classified and in eighteen cases biopsy was not performed. Excluded Cases. Seven patients were treated elsewhere; four of these had radiation therapy, two had surgery, and one had combined therapy. If these seven patients and the eighteen patients who had no biopsy are excluded, there are 173 remaining cases, and these form the basis of this report. Sez and Age
Treatment
and Results
Of these 173 patients, 105 were treated by
From the Thoracic Service, Memorial Hospital for Cancer and Allied Diseases, New York, New York. Presented at the Fifteenth Annual Meeting of The Society of Head and Neck Surgeons. Mexico City.Mexico, March 16-19. 1969. Vol. 118, November
1969
M.D.,
F.A.C.S.,
New York, New York
various modalities of radiation alone. Fourteen were treated by surgical excision alone, and twenty-eight had combined radiation and surgical excision of the tumor. Twenty-six patients received no definitive treatment. Surgical Excision. Of the fourteen patients treated by surgical excision only, seven patients had cervical esophagectomy and seven had cervical esophagectomy plus laryngectomy. Three patients had thoracic as well as cervical esophagectomy at the same time. In one of these three patients radical neck dissection was performed and reconstruction was never performed. Reconstruction was accompli’shed in the two other patients by anastomosing the stomach to the pharynx and to the cervical esophagus. In three other patients reconstruction was never achieved. Plastic reconstruction of the cervical esophagus was performed in seven patients in whom either skin tubes or flaps were used. In one case a colon transplant was used at a second stage for re-establishment of continuity. In this group of fourteen cases there were four postoperative deaths and one patient was lost to follow-up study. Two patients are still alive sixteen and twenty years, respectively. Thus, there are seven determinate cases for study of survival. The average survival is nineteen months, with variation in survival of from six to thirty-three months. Cervical esophagectomy: This procedure alone was used in seven cases with two postoperative deaths. (One of these had cervicothoracic esophagectomy and cervical esophagogastrostomy, surviving surgery only two days.) There is one long-term survivor and thus four determinate cases. The average survival in these four cases is twenty-one months with a variation of six to thirty-one months. The long-term survivor, still alive twenty years after surgery, had a postirradiation 673
fibrosarcoma of the cervical esophagus [Z]. She had been treated twice in England with radiation therapy for goiter twenty-nine years previously and again in this country. In 1948 she was seen by Dr. William L. Watson because of esophageal obstruction. Cervical esophagectomy, left thyroid lobectomy, and left lower neck dissection were carried out. Pathologic study of the specimen revealed a large fibrosarcoma of the esophagus and, in addition, she was found to have carcinoma of the thyroid gland. Shortly after surgery she was treated with radiation for basal cell carcinoma of the chin. Four years prior to surgery she had right radical mastectomy for carcinoma. After recovery from esophagectomy she had nine staged procedures for plastic reconstruction of the esophagus over a seventeen month period. Cervical esopsagectomy and Earyngectomy: Of the seven patients in this group there were two postoperative deaths. One has been lost to follow-up study and one is still alive sixteen years after surgery. There are three cases for study of survival and the average survival is 16.3 months. The variation in survival is seven to thirty-three months. Combined Surgical and Radiation Therapy. Twenty-eight patients were treated by this method. Five of these had extended surgery leading to cervicothoracic esophagectomy, three of whom did not and two of whom did have associated laryngectomy. Seven patients had associated radical neck dissection. One had partial neck dissection, two had neck dissection at a later date, one had bilateral neck dissection, and three had radical neck dissection with esophagolaryngectomy. Two had radon seed implant associated with cervicothoracic esophagectomy. Eight were reconstructed with either a tantalum mesh and skin graft or a tube pedicle graft. Two had reconstruction with a colon transplant [3]. One of the latter had one stage esophagolaryngectomy and colon transplant, surviving four months. The other had preoperative irradiation and esop’hagolaryngectomy, with a colon transplant at a later date. She is alive and in good health ten years after surgery. Seven patients had preoperative irradiation [4], two of whom received radiation elsewhere, and fifteen had postoperative irradiation at varying lengths of time after surgery, usually as a result of recurrence. 674
Of these twenty-eight patients there were two postoperative deaths; one patient had had esophagolaryngectomy and the other cervicothoracic esophagectomy with laryngectomy. Four patients are still alive and have survived five years or more. Of the remaining twenty-two patients the average survival is eighteen months, with variation in survival from one to seventy-five months. In this determinate group, one survived over six years (seven-five months) and two survived four years. Esophagectomy and radiation: There were thirteen patients in this group with one postoperative death (cervicothoracic resection) and three long-term survivors. One of these, who is alive nine years after surgery, had only partial esophagectomy with removal of the tumor, preceded by preoperative irradiation. The other two had cervical esophagectomy with radiation postoperatively at a later date [l],‘surviving twenty-eight and fourteen years, respectively. There are thus nine patients to determine survival and the average is 22.3 months, with variation of four to forty-eight months. Esophagolaryngectomy and radiation: Fifteen patients constituted this group. Three of these patients had additional radical neck dissection, one had bilateral neck dissection, and one had neck dissection at a later date. There was one postoperative death and only one long-term survivor, a forty-one year old white woman, who had preoperative irradiation and a colon transplant to restore continuity at a second stage. She is alive ten years post resection. There are thirteen cases for determination of survival and the average is fifteen months, with variation of one to seventy-five months. Survival in Surgical Cases. In determining five year survival the number of cases from 1928 through 1963 was used. During this period thirteen patients were treated by surgery alone with two surviving five years or more, a rate of 15.3 per cent. Twenty-six patients were treated with surgery and radiation, with five surviving five years or longer, a rate of 19.2 per cent. For the total thirty-nine cases, with seven survivors, the survival rate is 17.9 per cent. Radiation Therapy. This group of 105 patients has been divided into two series: those treated in the presurgical era from 1928 The American
Journel
of Surgery
Cancer of Cervical Esophagus
through 1939 and those treated between 1940 and 1968 inclusive. The modalities used in the presurgical era varied from 175 to 250 kv., in addition to the radium element pack. There were thirty-six patients in this series with two deaths within the thirty day period. There were two five year survivors, both of whom were treated with 200 kv. The number of determinate cases is therefore thirty-four with an average survival of 13.8 months. If the two long-term survivors are excluded, the average survival is six months. The variation in survival is 1 to 140 months. In the second series from 1940 through 1963, there were sixty-nine patients with six deaths within thirty days and three patients were lost to follow-up study. There was one five year survivor who received 250 kv. therapy. There were sixty determinate cases with an average survival of 9.5 months. If the longterm survivor is excluded, the average survival is 8.5 months. The variation in survival is one to sixty-eight months. Of the total number of 105 patients having received radiation therapy, eight died in the thirty day period and three were lost to follow-up study. There were three five-year survivors and ninety-four cases to determine survival. In these ninety-four cases, the average survival is eleven months. If the long-term survivors are excluded, the average survival is 7.6 months. The variation in survival is 1 to 140 months. Comparison of Survival. In comparing five year survival with the different types of treatment, five patients were eliminated since they have been treated since 1963. These include two patients treated with radiation, one with surgery alone, and two with combined therapy. In the radiation group with three survivors in 103 cases, the survival rate is 2.8 per cent. In the thirteen patients treated by surgery alone, there were two five-year survivors, a rate of 15.3 per cent. In those receiving combined therapy, five of twenty-six survived five years or more, a survival rate of 19.2 per cent. Thus, there were ten five-year survivors in a total of 142 cases, a survival rate of ‘7 per cent. The over-all five year survival rate, if the twenty-
Vol. 118, November 1969
six patients who received no treatment are included, is 5.9 per cent. In comparing these surgical results with those of cancer of the thoracic esophagus, it was recently reported [I] that of 260 patients with cancer of the thoracic esophagus treated surgically, there were sixteen five year survivors, a rate of 6.1 per cent. Conclusions 1. A fairly large group of cases of cancer of the cervical esophagus is presented, but the number of patients in each group is relatively small, especially when compared with cases of cancer of the thoracic esophagus. 2. Surgical excision of the diseased area appears to offer the best chance for survival (15.3 per cent), especially if combined with radiation therapy (19.2 per cent). 3. The best survival can probably be achieved with the use of preoperative irradiation followed by surgical excision; however, the number of cases in which this program was used for cancer of the cervical esophagus is too small for definite conclusions. 4. Staged procedures are to be preferred because long procedures or too much surgery at one session in these patients who are elderly and debilitated negates long-term survival by postoperative mortality. 5. The number of five year survivors in both the cervical and thoracic groups is small and appears to be sporadic regardless of the type of treatment. The factors present in those patients who survive for long periods are indeterminate and unknown. References 1.
GOODNER,J. T. Radiation and surgical treatment of cancer of the thoracic esophagus.
2.
WATEON, W. L. and CONVERSE,J. M. Reconstruction of the cervical esophagus. Phst. & Reconstruct. Surg., 11: 183, 1953. WATSON, W. L. and CLIFFTON, E. E. Total esophagoplasty using right colon. Cancer, 10: 488, 1957. CLIFFTON, E. E., GOODNER,J. T., and BRONSTEIN, E. Preoperative irradiation for cancer of the esophagus. Cancer, 13: 37, 1960. WATSON, W. L. Cancer of the cervical esophagus. Ann. Surg., 116 : 86,1942.
Am. J. Roentgenol.,
3. 4. 5.
105
: 523,1969.
675
This is a report on the treatment of cancer of the cervical esophagus during a period of over forty years extending from 1928 through 1968. During this period 1,904 cases of cancer of the esophagus were seen at Memorial Hospital. There were 1,706 cases of cancer of the thoracic esophagus and 198 cases of cancer of the cervical esophagus. Clinical
Data
Incidence. Of the 198 patients with cancer of the cervical esophagus 131 were male (66 per cent.) and 67 were female (34 per cent), a ratio of 2:l. In 260 cases of cancer of the thoracic esophagus treated surgically [I], the incidence of males to females was 77.4 and 22.6 per cent, a ratio of more than 3:l. Of the 198 cases of cancer of the cervical esophagus, the majority of patients fell in the fifty to fifty-nine and sixty to sixty-nine year age groups in both sexes. In the seventy to seventy-nine year age group there was a predominance of males over females. Pathology. Of the 198 cases, 173 (87 per cent) were squamous or epidermoid carcinomas. There were three cases of adenocarcinoma and one each of fibrosarcoma and mucoepidermoid carcinoma. Two cases were not classified and in eighteen cases biopsy was not performed. Excluded Cases. Seven patients were treated elsewhere; four of these had radiation therapy, two had surgery, and one had combined therapy. If these seven patients and the eighteen patients who had no biopsy are excluded, there are 173 remaining cases, and these form the basis of this report. Sez and Age
Treatment
and Results
Of these 173 patients, 105 were treated by
From the Thoracic Service, Memorial Hospital for Cancer and Allied Diseases, New York, New York. Presented at the Fifteenth Annual Meeting of The Society of Head and Neck Surgeons. Mexico City.Mexico, March 16-19. 1969. Vol. 118, November
1969
M.D.,
F.A.C.S.,
New York, New York
various modalities of radiation alone. Fourteen were treated by surgical excision alone, and twenty-eight had combined radiation and surgical excision of the tumor. Twenty-six patients received no definitive treatment. Surgical Excision. Of the fourteen patients treated by surgical excision only, seven patients had cervical esophagectomy and seven had cervical esophagectomy plus laryngectomy. Three patients had thoracic as well as cervical esophagectomy at the same time. In one of these three patients radical neck dissection was performed and reconstruction was never performed. Reconstruction was accompli’shed in the two other patients by anastomosing the stomach to the pharynx and to the cervical esophagus. In three other patients reconstruction was never achieved. Plastic reconstruction of the cervical esophagus was performed in seven patients in whom either skin tubes or flaps were used. In one case a colon transplant was used at a second stage for re-establishment of continuity. In this group of fourteen cases there were four postoperative deaths and one patient was lost to follow-up study. Two patients are still alive sixteen and twenty years, respectively. Thus, there are seven determinate cases for study of survival. The average survival is nineteen months, with variation in survival of from six to thirty-three months. Cervical esophagectomy: This procedure alone was used in seven cases with two postoperative deaths. (One of these had cervicothoracic esophagectomy and cervical esophagogastrostomy, surviving surgery only two days.) There is one long-term survivor and thus four determinate cases. The average survival in these four cases is twenty-one months with a variation of six to thirty-one months. The long-term survivor, still alive twenty years after surgery, had a postirradiation 673
fibrosarcoma of the cervical esophagus [Z]. She had been treated twice in England with radiation therapy for goiter twenty-nine years previously and again in this country. In 1948 she was seen by Dr. William L. Watson because of esophageal obstruction. Cervical esophagectomy, left thyroid lobectomy, and left lower neck dissection were carried out. Pathologic study of the specimen revealed a large fibrosarcoma of the esophagus and, in addition, she was found to have carcinoma of the thyroid gland. Shortly after surgery she was treated with radiation for basal cell carcinoma of the chin. Four years prior to surgery she had right radical mastectomy for carcinoma. After recovery from esophagectomy she had nine staged procedures for plastic reconstruction of the esophagus over a seventeen month period. Cervical esopsagectomy and Earyngectomy: Of the seven patients in this group there were two postoperative deaths. One has been lost to follow-up study and one is still alive sixteen years after surgery. There are three cases for study of survival and the average survival is 16.3 months. The variation in survival is seven to thirty-three months. Combined Surgical and Radiation Therapy. Twenty-eight patients were treated by this method. Five of these had extended surgery leading to cervicothoracic esophagectomy, three of whom did not and two of whom did have associated laryngectomy. Seven patients had associated radical neck dissection. One had partial neck dissection, two had neck dissection at a later date, one had bilateral neck dissection, and three had radical neck dissection with esophagolaryngectomy. Two had radon seed implant associated with cervicothoracic esophagectomy. Eight were reconstructed with either a tantalum mesh and skin graft or a tube pedicle graft. Two had reconstruction with a colon transplant [3]. One of the latter had one stage esophagolaryngectomy and colon transplant, surviving four months. The other had preoperative irradiation and esop’hagolaryngectomy, with a colon transplant at a later date. She is alive and in good health ten years after surgery. Seven patients had preoperative irradiation [4], two of whom received radiation elsewhere, and fifteen had postoperative irradiation at varying lengths of time after surgery, usually as a result of recurrence. 674
Of these twenty-eight patients there were two postoperative deaths; one patient had had esophagolaryngectomy and the other cervicothoracic esophagectomy with laryngectomy. Four patients are still alive and have survived five years or more. Of the remaining twenty-two patients the average survival is eighteen months, with variation in survival from one to seventy-five months. In this determinate group, one survived over six years (seven-five months) and two survived four years. Esophagectomy and radiation: There were thirteen patients in this group with one postoperative death (cervicothoracic resection) and three long-term survivors. One of these, who is alive nine years after surgery, had only partial esophagectomy with removal of the tumor, preceded by preoperative irradiation. The other two had cervical esophagectomy with radiation postoperatively at a later date [l],‘surviving twenty-eight and fourteen years, respectively. There are thus nine patients to determine survival and the average is 22.3 months, with variation of four to forty-eight months. Esophagolaryngectomy and radiation: Fifteen patients constituted this group. Three of these patients had additional radical neck dissection, one had bilateral neck dissection, and one had neck dissection at a later date. There was one postoperative death and only one long-term survivor, a forty-one year old white woman, who had preoperative irradiation and a colon transplant to restore continuity at a second stage. She is alive ten years post resection. There are thirteen cases for determination of survival and the average is fifteen months, with variation of one to seventy-five months. Survival in Surgical Cases. In determining five year survival the number of cases from 1928 through 1963 was used. During this period thirteen patients were treated by surgery alone with two surviving five years or more, a rate of 15.3 per cent. Twenty-six patients were treated with surgery and radiation, with five surviving five years or longer, a rate of 19.2 per cent. For the total thirty-nine cases, with seven survivors, the survival rate is 17.9 per cent. Radiation Therapy. This group of 105 patients has been divided into two series: those treated in the presurgical era from 1928 The American
Journel
of Surgery
Cancer of Cervical Esophagus
through 1939 and those treated between 1940 and 1968 inclusive. The modalities used in the presurgical era varied from 175 to 250 kv., in addition to the radium element pack. There were thirty-six patients in this series with two deaths within the thirty day period. There were two five year survivors, both of whom were treated with 200 kv. The number of determinate cases is therefore thirty-four with an average survival of 13.8 months. If the two long-term survivors are excluded, the average survival is six months. The variation in survival is 1 to 140 months. In the second series from 1940 through 1963, there were sixty-nine patients with six deaths within thirty days and three patients were lost to follow-up study. There was one five year survivor who received 250 kv. therapy. There were sixty determinate cases with an average survival of 9.5 months. If the longterm survivor is excluded, the average survival is 8.5 months. The variation in survival is one to sixty-eight months. Of the total number of 105 patients having received radiation therapy, eight died in the thirty day period and three were lost to follow-up study. There were three five-year survivors and ninety-four cases to determine survival. In these ninety-four cases, the average survival is eleven months. If the long-term survivors are excluded, the average survival is 7.6 months. The variation in survival is 1 to 140 months. Comparison of Survival. In comparing five year survival with the different types of treatment, five patients were eliminated since they have been treated since 1963. These include two patients treated with radiation, one with surgery alone, and two with combined therapy. In the radiation group with three survivors in 103 cases, the survival rate is 2.8 per cent. In the thirteen patients treated by surgery alone, there were two five-year survivors, a rate of 15.3 per cent. In those receiving combined therapy, five of twenty-six survived five years or more, a survival rate of 19.2 per cent. Thus, there were ten five-year survivors in a total of 142 cases, a survival rate of ‘7 per cent. The over-all five year survival rate, if the twenty-
Vol. 118, November 1969
six patients who received no treatment are included, is 5.9 per cent. In comparing these surgical results with those of cancer of the thoracic esophagus, it was recently reported [I] that of 260 patients with cancer of the thoracic esophagus treated surgically, there were sixteen five year survivors, a rate of 6.1 per cent. Conclusions 1. A fairly large group of cases of cancer of the cervical esophagus is presented, but the number of patients in each group is relatively small, especially when compared with cases of cancer of the thoracic esophagus. 2. Surgical excision of the diseased area appears to offer the best chance for survival (15.3 per cent), especially if combined with radiation therapy (19.2 per cent). 3. The best survival can probably be achieved with the use of preoperative irradiation followed by surgical excision; however, the number of cases in which this program was used for cancer of the cervical esophagus is too small for definite conclusions. 4. Staged procedures are to be preferred because long procedures or too much surgery at one session in these patients who are elderly and debilitated negates long-term survival by postoperative mortality. 5. The number of five year survivors in both the cervical and thoracic groups is small and appears to be sporadic regardless of the type of treatment. The factors present in those patients who survive for long periods are indeterminate and unknown. References 1.
GOODNER,J. T. Radiation and surgical treatment of cancer of the thoracic esophagus.
2.
WATEON, W. L. and CONVERSE,J. M. Reconstruction of the cervical esophagus. Phst. & Reconstruct. Surg., 11: 183, 1953. WATSON, W. L. and CLIFFTON, E. E. Total esophagoplasty using right colon. Cancer, 10: 488, 1957. CLIFFTON, E. E., GOODNER,J. T., and BRONSTEIN, E. Preoperative irradiation for cancer of the esophagus. Cancer, 13: 37, 1960. WATSON, W. L. Cancer of the cervical esophagus. Ann. Surg., 116 : 86,1942.
Am. J. Roentgenol.,
3. 4. 5.
105
: 523,1969.
675