Esophageal resection in elderly esophageal carcinoma patients: improvement in postoperative complications

BACKGROUND: Advanced age is considered to be a relative contraindication for radical esophagectomy with a three-field lymph node dissection. METHODS: Preoperative risks, postoperative morbidity and mortality, and long-term survival in 55 elderly patients (> or =70 years) who had undergone extensive esophagectomy for esophageal carcinoma were compared with those of 149 younger patients (<70 years). RESULTS: Elderly patients had worse preoperative cardiopulmonary function and had more frequent postoperative cardiopulmonary complications compared with younger patients (p < 0.05). The postoperative death rate was not statistically different between the elderly (10.9%) and younger groups (5.4%). When the study period was divided into an early and a late phase, the postoperative death rate dropped significantly (p < 0.05) in recent years (1.4%) when compared with the previous era (10.0%). The overall survival rates were not different between elderly and younger patients. CONCLUSIONS: Preoperative cardiopulmonary risk factors and postoperative complications after esophagectomy were more frequently noticed in elderly patients than in younger patients. A dramatic improvement in postoperative death was noticed in recent years. The long-term survival of elderly patients after extended esophagectomy was almost similar to that in younger patients.     

Surgical treatment of carcinoma of the hypopharynx and cervical esophagus]

Between 1975 and 1988 we observed 169 patients with carcinoma of the cervical esophagus, 85 a carcinoma involving the hypopharynx and the cervical esophagus, and 27 patients with a carcinoma of the cervical esophageal region arose after laryngectomy for laryngeal cancer. The mean age was 57.5 years (range 41-73). 167 patients underwent surgical exploration (operability rate 59.5%) and in 152 cases the tumor was resected (resectability rate 91.1%). The resection was complete in 129 patients (84.9%) and palliative in 23 (14.1%). In 33 cases of laryngo-pharyngo-cervical segmentary esophagectomy with free intestinal loop transplantation was performed with an operative mortality of 6.1%. 101 patients underwent laryngo-pharyngo-total esophagectomy and the digestive tract was reconstructed by means of pharyngo-gastrostomy and pharyngo-colostomy in 85 and 16 cases, with an operative mortality of 12.9% and 18.3%, respectively. Total esophagectomy without laryngectomy was performed in 18 patients with a carcinoma of the distal cervical esophagus refusing laryngectomy with an hospital mortality of 5.5%. The overall 5-year actuarial survival, excluding the operative mortality, was 15.8%. After complete resection, better results were recorded with patients operated for carcinoma of the hypopharynx than with patients with carcinoma of the cervical esophagus: the 2-year and 5-year actuarial survival was 59% vs 26% and 43% vs 17%, respectively. No patient undergoing palliative resection was alive at the 3-year interval.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical treatment for carcinoma of the esophagus in the elderly patient.

Sixty-three elderly patients with carcinoma of the esophagus were operated upon in the department of chest cancer in Tianjin Cancer Hospital from January 1978 to January 1992. Eleven patients had a tumor located in the upper part of the thoracic esophagus; 30 patients in the middle part and 22 patients in the lower part. Squamous cell carcinoma was 55 cases, adenocarcinoma was 7 cases and small cell carcinoma was 1 case. The classification by stages according to criteria established by UICC, based on operative evaluation, showed 3 patients in stage I; 24 patients in stage II and 25 patients in stage III. Forty-seven patients were operated as "curative" resection, 5 patients as "palliative" resection and 11 patients underwent exploratory laparotomy or thoracotomy alone. The total resection rate was 82.5%. For tumors in the upper thoracic part of the esophagus, a total esophagectomy was performed using the triple approach. In the remaining patients, a subtotal esophagectomy was performed using the Sweet technique. There were no operative deaths in all patients. One or more postoperative complications were seen in 16 patients (25.4%). The most frequently recorded complications were pulmonary ones. The survival rate at two, three and five years were respectively 65, 35 and 20% in patients who underwent "curative" resection. The survival rates for patients in whom resection was considered "palliative" was zero after 3 years and for patients who received exploration alone was zero after one year. The survival rates at 3 years for patients who underwent "curative" resection were respectively 100, 35 and 25% in stage I, stage II and staged III. We hold the view that the esophagectomy is still a predominant measure for esophageal carcinoma in the elderly and limited surgery (palliative resection) was recommended in consideration of the postoperative quality of life. If the elderly can tolerate the operative procedure, long-term survival with excellent functional status is attainable in this age group.     

Cancer of the hypopharynx and cervical esophagus. Role and limits of the surgical treatment

From 1975 to 1988, we observed 169 patients with a carcinoma of the cervical esophagus, 85 with a carcinoma involving the hypopharynx and the cervical esophagus, and 27 with a carcinoma of the cervical esophagus occurring after laryngectomy for laryngeal carcinoma. The average age was 57.5 years (41-73). Exploration was surgical for 167 patients (operability ratio 59.5%), and the lesion was resected in 152 cases (resectability ratio 81.1%). Resection was complete in 129 patients (84.5%) and palliative in 23 (14.5%). A laryngopharyngoesophagectomy involving the cervical esophagus and requiring the transplantation of a free intestinal loop was performed in 33 cases, with an operative mortality rate of 6.1%. Pharyngolaryngectomy with total esophagectomy was performed in 101 patients, and the digestive tract was reconstructed by means of pharyngogastrostomy or pharyngocolostomy (respectively 85 and 16 cases) with an operative mortality rate of 12.9% and 18.3%, respectively. Complete esophagectomy without laryngectomy was performed for 18 patients with carcinoma of the distal cervical esophagus who refused laryngectomy, the hospital mortality rate being of 5.5%. The actuarial survival rate after 5 years (not including operative mortality) was 15.8%. Better results were achieved after complete resection for carcinoma of the hypopharynx than for carcinoma of the cerebral esophagus. The actuarial survival rates after 2 and 5 years were 59% vs. 26% and 43% vs. 17% respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pancreatic or liver resection for malignancy is safe and effective for the elderly.

BACKGROUND: Liver resection, or pancreaticoduodenectomy, has traditionally been thought to have a high morbidity and mortality rate among the elderly. Recent improvements in surgical and anesthetic techniques, an increasing number of elderly patients, and an increasing need to justify use of limited health care resources prompted an assessment of recent surgical outcomes. METHODS: Five hundred seventy-seven liver resections (July 1985-July 1994) performed for metastatic colorectal cancer and 488 pancreatic resections (October 1983-July 1994) performed for pancreatic malignancies were identified in departmental data bases. Outcomes of patients younger than age 70 years were compared with those of patients age 70 years or older. RESULTS: Liver resection for 128 patients age 70 years or older resulted in a 4% perioperative mortality rate and a 42% complication rate. Median hospital stay was 13 days, and 8% of the patients required admission to the intensive care unit (ICU). Median survival was 40 months, and the 5-year survival rate was 35%. No differences were found between results for the elderly and those for younger patients who had undergone liver resection, except for a minimally shorter hospital stay for the younger patients (median, 12 days vs. 13 days; p = 0.003). Pancreatic resection for 138 elderly patients resulted in a mortality rate of 6% and a complication rate of 45%. Median stay was 20 days, and 19% of the patients required ICU admission, results identical to those for the younger cohort. Long-term survival was poorer for the elderly patients, with a 5-year survival rate of 21% compared with 29% for the younger cohort (p = 0.03). CONCLUSIONS: Major liver or pancreatic resections can be performed for the elderly with acceptable morbidity and mortality rates and possible long-term survival. Chronological age alone is not a contraindication to liver or pancreatic resection for malignancy.     

Cancer of the hypopharynx and cervical esophagus

Between 1975 and 1988 we observed 169 patients with carcinoma of the cervical esophagus, 85 with a carcinoma involving the hypopharynx and the cervical esophagus, and 27 patients with a carcinoma of the cervical esophageal region arising after laryngectomy for laryngeal cancer. The mean age was 57.5 years (range 41-73). 167 patients underwent surgical exploration (operability rate 59.5%) and in 152 cases the tumor was resected (resectability rate 91.1%). The resection was complete in 129 patients (84.5%) and palliative in 23 (14.5%). In 33 cases a segmental laryngo-pharyngo-cervical esophagectomy with free intestinal loop transplantation was performed with an operative mortality of 6.1%. 101 patients underwent total laryngo-pharyngo esophagectomy and the gastrointestinal tract was reconstructed by means of pharyngo-gastrostomy and pharyngo-colostomy in 85 and 16 cases, with an operative mortality of 12.9% and 18.3%, respectively. Total esophagectomy without laryngectomy was performed in 18 patients with a carcinoma of the distal cervical esophagus refusing laryngectomy with a hospital mortality of 5.5%. The overall 5-year actuarial survival, excluding the operative mortality, was 15.8%. After complete resection, better results were recorded with patients operated for carcinoma of the hypopharynx than with patients with carcinoma of the cervical esophagus: the 2-year and 5-year actuarial survival was 59% vs 26% and 43% vs 17%, respectively. No patient undergoing palliative resection was alive at the 3-year interval.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgery for oesophageal carcinoma in the elderly.

OBJECTIVE: There has been a gradual increase in the number of elderly patients referred for oesophageal surgery. The aim of this study is to review our experience with oesophageal cancer surgery in the elderly. METHODS: Between January 1974 and December 1996, 591 patients (408 males, 183 females; mean age 66 years) underwent an oesophageal resection for carcinoma. 221 were aged greater than 70 years of age (group A) and 370 less than 70 (group B). RESULTS: Total in hospital mortality was 8.8% (52/591). This has decreased to less than 5% over the last decade. There was no significant difference in perioperative morbidity or mortality between the groups (P = 0.11). When deaths from unrelated medical conditions were excluded, there was no significant difference in survival between the different age groups (P = 0.96). CONCLUSION: Oesophageal surgery can be performed in a selected elderly population with a low operative morbidity and mortality. The survival benefit of resection is the same in the elderly as for younger patients.     

Liver and Pancreatic Resection in the Elderly

Background: Liver resection, or pancreaticoduodenectomy, has traditionally been thought to have a high morbidity and. mortality rate among the elderly. Recent improvements in surgical and anesthetic techniques, an increasing number of elderly patients, and an increasing need to justify use of limited health care resources prompted an assessment of recent surgical outcomes.Methods: Five hundred seventy-seven liver resections (July 1985–July 1994) performed for metastatic colorectal cancer and 488 pancreatic resections (October 1983–July 1994) performed for pancreatic malignancies were identified in departmental data bases. Outcomes of patients younger than age 70 years were compared with those of patients age 70 years or older.Results: Liver resection for 128 patients age 70 years or older resulted in a 4% perioperative. mortality rate and a 42% complication rate. Median hospital stay was 13 days, and 8% of the patients required admission to the intensive care unit (ICU). Median survival was 40 months, and the 5-year survival rate was 35%. No difference were found between results for the elderly and those for younger patients who had undergone liver resection, except for a minimally shorter hospital stay fortheyoungerpatients (median, 12 days vs. 13 days p=0.003). Pancreatic resection for 138 elderly patients resulted in a mortality rate of 6% and a complication rate of 45%. Median stay was 20 days, and 19% of the patients required ICU admission, results identical to those for the younger cohort. Long-term survival was poorer for the elderly patients, with a 5-year survival rate of 21% compared with 29% for the younger cohort (p=0.03).Conclusions: Major liver or pancreatic resections can be performed for the elderly with acceptable morbidity and mortality rates and possible long-term survival. Chronologic age alone is not a contraindication to liver or pancreatic resection for malignancy.     

Role of Esophagectomy in Treatment of Esophageal Carcinoma with Clinical Evidence of Adjacent Organ Invasion

With carcinoma of the thoracic esophagus, clinical evidence of invasion of adjacent organs (T4) indicates a highly advanced stage, and most surgeons avoid esophagectomy. Although the therapeutic strategy for such disease is generally selected based on preoperative evaluation and intraoperative inspection, their accuracy and the relation to survival outcomes after esophagectomy have seldom been analyzed on the basis of exact histopathologic evidence. We performed esophagectomy, with perioperative adjuvant therapy when possible, on patients with clinical-T4 tumors unless absolutely unresectable conditions were detected. Among the 500 patients who underwent esophagectomy, the 78 patients whose tumors were confirmed to be T4 pathologically were compared with patients whose tumors were assessed as T4 preoperatively or intraoperatively to evaluate the role of esophagectomy for clinical-T4 carcinoma. Esophagectomy was possible for 99% of the pathologic-T4 tumors preoperatively assessed as resectable, but the resection was grossly incomplete in 35%. The true-positive rates in tumors preoperatively and intraoperatively assessed as T4 were 51% and 84%, respectively. The hospital mortality rate in patients with pathologic-T4 tumors was 4%. The overall 5-year survival rate for patients with pathologic-T4 tumors was 14%, compared with 60% for those with tumors assessed as T4 intraoperatively but not pathologically. Esophagectomy with perioperative adjuvant therapy yielded occasional cure with an acceptable mortality rate for patients with pathologic-T4 tumors assessed as technically resectable. Preoperative assessment and intraoperative macroscopic inspection had limitations for predicting pathologic-T4 disease and incomplete resection. Only patients with definitive evidence of unresectability should be excluded from esophagectomy.     

Improvement in the results of surgical treatment of advanced squamous esophageal carcinoma during 15 consecutive years

OBJECTIVE: To document the clinicopathologic characteristics and survival of patients undergoing esophagectomy for squamous carcinoma of the thoracic esophagus, and to examine the factors contributing to improvements in outcome noted in patients with advanced carcinoma. SUMMARY BACKGROUND DATA: Japanese and some Western surgeons recently have reported that radical esophagectomy with extensive lymphadenectomy conferred a survival advantage to patients with esophageal carcinoma. The factors contributing to this improvement in results have not been well defined. METHODS: From 1981 to 1995, 419 patients with carcinoma of the thoracic esophagus underwent esophagectomy at the Keio University Hospital. The clinicopathologic characteristics and survival of patients treated between 1981 and 1987 were compared with those of patients treated between 1988 and 1995. Multivariate analysis using the Cox regression model was carried out to evaluate the impact of 15 variables on survival of patients with p stage IIa to IV disease. Several variables related to prognosis were examined to identify differences between the two time periods. RESULTS: The 5-year survival rate for all patients was 40.0%. The 5-year survival rate was 17.7% for p stage IIa to IV patients treated during the earlier period and 37.6% for those treated during the latter period. The Cox regression model revealed seven variables to be important prognostic factors. Of these seven, three (severity of postoperative complications, degree of residual tumor, and number of dissected mediastinal nodes) were found to be significantly different between the earlier and latter periods. CONCLUSIONS: The survival of patients undergoing surgery for advanced carcinoma (p stage IIa to IV) of the thoracic esophagus has improved during the past 15 years. The authors' data suggest that this improvement is due mainly to advances in surgical technique and perioperative management.     

Surgical treatment of advanced colorectal cancer in the elderly

The aim of the study was to compare the short and long-term outcomes of older and younger colorectal cancer patients with advanced disease resected with a curative intent. Six hundred and ninety-two patients were analysed. Four hundred and seventy-nine patients were younger than 70 years (Group 1), and 213 were 70 years of age or above (Group 2). The overall perioperative mortality rate in the younger group was 0.8% (n = 7), as against 1.4% (n = 3) in the elderly group (p = NS). The morbidity rates were 35% and 42%, respectively (p = NS). At univariate analysis, the elderly patients had a worse overall survival compared to the younger group, when only patients undergoing postoperative chemo-radiotherapy were considered (54% vs 67% overall survival at 5 years; p = 0.03). Using logistic regression analysis, tumour stage (p < 0.0001) and radicality of surgery (p < 0.0001) correlated significantly with overall survival rates in the elderly. Colorectal surgery for malignancy can be performed safely in the elderly with acceptable morbidity and mortality rates and long-term survival.     

Indicators of prognosis after transhiatal esophageal resection without thoracotomy for cancer

BACKGROUND: Various techniques have been described for the surgical treatment of esophageal cancer. The transhiatal approach has been debated for its safety and oncologic results. STUDY DESIGN: Between January 1993 and September 1996, 115 patients underwent a transhiatal esophagectomy with curative intent for adenocarcinoma or squamous cell carcinoma of the middle or distal esophagus or esophagogastric junction. Procedure-related hazards, pathologic results, and prognostic factors for survival were evaluated. Median duration of postoperative followup was 27 months (range 1 to 74 months) for all patients and 45 months (range 30 to 74 months) for those alive at final followup. RESULTS: No emergency thoracotomies were experienced. In-hospital mortality was 3.5%. Vocal cord dysfunction (24%) and pulmonary complications (23%) were the most frequent early postoperative complications. A microscopically radical resection was achieved in 73% of patients. Overall survival was 45% at 3 years. In univariate analysis, the most pronounced indicators of longterm survival (p < 0.0001) were radicality of the resection, lymph node involvement, lymph node ratio (ie, the ratio of invaded to removed lymph nodes), and pathologic tumor stage. Multivariate analysis identified the lymph node ratio (p < 0.0001) as the strongest independent predictor of long-term survival, followed by radicality of the resection (p = 0.0064) and duration of ICU stay (p = 0.027). CONCLUSION: Transhiatal esophagectomy without thoracotomy can be considered a safe procedure for resectable cancer of the midesophagus, distal esophagus, or esophagogastric junction. Radicality and survival results were in line with the data reported for traditional transthoracic approaches. A prognostic value of the lymph node ratio was observed. It emphasizes the need for controlled trials aimed at delineating the prognostic impact of an extended lymph node dissection.     

Outcomes in octogenarians undergoing high-risk cancer operation: a national study

BACKGROUND: Current information about outcomes in octogenarians undergoing cancer operations is limited largely to case series from selected centers. Population-based data can provide more realistic estimates of the risks and benefits of operations in this group. STUDY DESIGN: We performed a retrospective cohort study of patients undergoing major resections for lung, esophageal, and pancreas cancer. Using the Nationwide Inpatient Sample (1994 to 2003), we examined operative mortality and discharge disposition in octogenarians (aged 80+ years), relative to younger patients (aged 65 to 69 years) (n = 272,662). We then used the Surveillance and End Results-Medicare-linked database (1992 to 2001) to measure late survival in the elderly (n = 14,088). RESULTS: Operative mortality among octogenarians was substantially higher than that of younger patients (aged 65 to 69 years) for all three cancers (esophagectomy, 19.9% versus 8.8%, p < 0.0001; pancreatectomy, 15.5% versus 6.7%, p < 0.0001; lung resection, 6.9% versus 3.7%, p < 0.0001). A large proportion of octogenarians were transferred to extended care facilities after operation, ranging from 24% after lung resection to 44% after esophagectomy. Five-year survival in octogenarians was low for all three cancers: 11% after pancreatectomy, 18% after esophagectomy and 31% after lung cancer resection. Survival among octogenarians with two or more comorbidities was worse than those with fewer comorbid diagnoses--10% versus 14% for pancreatectomy, 15% versus 23% for esophagectomy, and 27% versus 37% for lung resection. CONCLUSIONS: Population-based outcomes after high-risk cancer operation in octogenarians are considerably worse than typically reported in case series and published survival statistics. Such information might better inform clinical decision making in this high-risk group.     

Results of colectomy in elderly patients with colon cancer, based on Medicare claims data.

Currently available estimates of outcomes following colon resection in elderly patients with colon cancer are based on series collected at academic medical centers. We used Medicare Part A claims and enrollment records of a 5% nationally random sample of elderly Medicare beneficiaries from 1983 to 1985 to estimate how patient age and sex affected perioperative mortality and 1- and 2-year survival rates among elderly patients undergoing a colon resection procedure for colon cancer. Among the 5,586 individuals in our data set, the overall perioperative mortality rate was 5.0%, ranging from 3.3% in beneficiaries 66 to 69 years of age to 9.3% in those 85 years of age and older. Men had a 31% higher perioperative mortality rate than women (5.8% versus 4.4%, p less than 0.05). The overall postoperative survival rates at 1 and 2 years were 72% and 63%, respectively, decreasing with increasing age, but were similar in men and women. This analysis provides age- and sex-specific estimates of outcomes following surgery for elderly patients with colon cancer that are more precise and have more potential for generalization than those that were available previously.     

Effects of Neoadjuvant Therapy on Perioperative Morbidity in Elderly Patients Undergoing Esophagectomy for Esophageal Cancer

Background The use of cytoreductive therapy followed by surgery is preferred by many centers dealing with locally advanced esophageal cancer. However, the potential for increase in mortality and morbidity rates has raised concerns on the use of chemoradiation therapy, especially in elderly patients. The aim of this study was to assess the effects of induction therapy on postoperative mortality and morbidity in elderly patients undergoing esophagectomy for locally advanced esophageal cancer at a single institution. Methods Postoperative mortality and morbidity of patients ≥70 years old undergoing esophagectomy after neoadjuvant therapy, between January 1992 and October 2005 for cancer of the esophagus or esophagogastric junction, were compared with findings in younger patients also receiving preoperative cytoreductive treatments. Results 818 patients underwent esophagectomy during the study period. The study population included 238 patients <70 years and 31 ≥70 years old undergoing esophageal resection after neoadjuvant treatment. Despite a significant difference in comorbidities (pulmonary, cardiological and vascular), postoperative mortality and morbidity were similar irrespective of age. Conclusions Elderly patients receiving neoadjuvant therapies for cancer of the esophagus or esophagogastric junction do not have a significantly increased prevalence of mortality and major postoperative complications, although cardiovascular complications are more likely to occur. Advanced age should no longer be considered a contraindication to preoperative chemoradiation therapy preceding esophageal resection in carefully selected fit patients.     

Ivor Lewis operation for epidermoid carcinoma of the esophagus

One hundred patients, 95 men and 5 women with a mean age of 59 years (age range, 35 to 77 years), were treated by the same initiate surgeon in practice from 1982 to 1988 for epidermoid carcinoma of the lower two-thirds of the esophagus using the Ivor Lewis procedure. Fifty-eight tumors were located in the middle third of the esophagus and 42, in the lower third. Postoperative staging revealed 30 stage I/II and 70 stage III carcinomas (ie, tumors extending beyond the esophageal wall or lymph node extension). Operative procedure was considered curative in 70 patients and palliative in 30 patients. The same procedure has been used for all patients. In all patients we were able to perform extended esophagectomy with anastomosis located 3 to 7 cm under the pharyngoesophageal junction. Postoperative mortality was 4%. Morbidity due to leakage was 7%; proper drainage enabled spontaneous healing in 5 patients. Fifteen patients had pulmonary complications, none of which fatal, Median actuarial survival was 17 months. Actuarial survival at 24 months is significantly higher for patients in stage I and II (68.4%) than for patients in stage III (23.2%) (p less than 0.01). The Ivor Lewis procedure is a safe surgical approach for the treatment of the esophageal carcinoma that has a high survival rate and allows a good quality of life.     

Barrett''s esophagus with high-grade dysplasia. An indication for prophylactic esophagectomy.

OBJECTIVE. The authors review the results and outcomes of esophagectomy (prophylactic esophagectomy) for patients with Barrett's esophagus and high-grade epithelial dysplasia (HGD). SUMMARY BACKGROUND DATA. The role of prophylactic esophagectomy for Barrett's esophagus with HGD is controversial, with some authors recommending surgery and others favoring endoscopic surveillance until biopsy diagnosis of carcinoma is made. METHODS. Between 1982 and 1994, 30 consecutive patients with HGD underwent esophagectomy and had the pre- and postoperative pathology reviewed at our institution. The medical records were reviewed to determine patient characteristics, preoperative endoscopic data, surgical approach, operative morbidity and mortality, length of hospitalization, and treatment outcome. Patients were divided into two groups based on whether invasive adenocarcinoma was found in the resection specimen (group 1) or not (group 2). RESULTS. The duration of reflux symptoms was 22 +/- 14 years for group 1 and 9 +/- 11 years for group 2 (p = 0.05). There was one operative death (3.3%) and six complications (20%). In 13 patients (43%, group 1), invasive adenocarcinoma was found in the resected esophagus. The American Joint Committee on Cancer stage for these patients was stage I (8 patients), stage II (2 patients), and stage III (3 patients). One stage I patient died of adenocarcinoma (72 months) in an incompletely excised HGD segment. Other stage I and II patients are alive without adenocarcinoma with an 18-and 63-month mean follow-up, respectively. Outcome for stage III patients was one operative death, one noncancer death (6 months), and one patient with metastatic adenocarcinoma (26 months). For group 2 (57%), there were no adenocarcinoma deaths (40 months). CONCLUSIONS. High-grade epithelial dysplasia is an indication for esophagectomy because of the prevalence of occult adenocarcinoma (43%). Esophagectomy can be performed safely, and survival in patients with completely resected Barrett's esophagus and early-stage adenocarcinoma is excellent.     

Preoperative chemoradiation therapy does not improve early survival after esophagectomy for patients with clinical stage III adenocarcinoma of the esophagus

BACKGROUND: The optimal treatment for locally advanced esophageal cancer remains controversial. The objective of this study was to determine if preoperative chemoradiation therapy (P-CRT) followed by esophagectomy for patients with clinical stage III adenocarcinoma of the esophagus offered any survival advantage as compared with esophagectomy alone. METHODS: Between January 1998 and June 2001, 75 nonrandomized patients with clinical stage III adenocarcinoma of the esophagus underwent either P-CRT and esophagectomy or esophagectomy alone. All patients were staged before initiation of treatment with computed tomography and endoscopic ultrasound. RESULTS: P-CRT followed by esophagectomy was performed in 47 patients (63%) and esophagectomy alone in 28 patients (37%). Although the P-CRT group was younger (median age, 61 years versus 67 years), the two groups were otherwise similar for gender, comorbidities, and symptoms. Overall operative mortality was 4%. Follow-up was complete in all patients and ranged from 5 to 40 months (median, 20 months). Overall, one-, two-, and three-year survivals were 72%, 44%, and 42%, respectively. Three-year survival was identical (42%) for both the P-CRT and surgery alone patients (p = 0.70). Three-year disease-free survival for the P-CRT group was 29% as compared with 33% for the surgery only group (p = 0.51). CONCLUSIONS: Patients with clinical stage III adenocarcinoma of the esophagus do not appear to gain an early overall or disease-free survival advantage when treated with P-CRT followed by surgery as compared with surgery alone. However, long-term follow-up is needed. A large, prospective, randomized trial is warranted to address the question of whether P-CRT offers any survival benefit or impact on pattern of recurrence in patients undergoing esophagectomy for locally advanced disease.     

Adenocarcinoma of the esophagus.

Adenocarcinoma involving the distal esophagus usually is far advanced when the patient is first seen. Adenocarcinoma differs from squamous carcinoma of the esophagus since it is relatively unresponsive to radiation therapy or chemotherapy. Adenocarcinoma of the esophagus resembles gastric cancer in its tendency to form a bulky and locally invasive tumor with early regional lymph node metastases. It differs from gastric cancer in its tendency to spread proximally in the esophagus and in the relatively infrequent early involvement of the liver by metastases. From 1979-1986, 37 patients had resection for adenocarcinoma involving the distal esophagus. Thirty-three patients were diagnosed with American Joint Committee for Cancer Stage III or IV adenocarcinoma at the time of operation. Transhiatal esophagectomy in continuity with a proximal gastrectomy was done in 27 patients. Reconstruction was accomplished by cervical esophagogastrostomy using pedicled distal stomach. There were three postoperative deaths (30-day mortality rate: 8%). Anastomotic leak occurred in nine patients and caused significant morbidity in four patients. Eleven patients required dilation of the cervical anastomosis after operation for up to 6 months. Mediastinal recurrence affected three patients treated by transhiatal esophagectomy. The survival rate (Kaplan-Meier) was 44% at 1 year and 31% at 2 years. Resection of adenocarcinoma of the esophagus can be accomplished in most patients with acceptable risks of morbidity and mortality. Resection restores ability to swallow saliva and to consume a normal diet, and is associated with an appreciable improvement in the quality of life.     

Craniofacial resections in the elderly: an outcome study

OBJECT: The elderly population is increasing in number and is healthier now than in the past. The purpose of this study was to examine complications and outcomes following craniofacial resection (CFR) in elderly patients and to compare findings with those of a matched younger cohort. METHODS: All patients 70 years of age or older undergoing CFR at the M.D. Anderson Cancer Center (elderly group) between December 1992 and July 2003 were identified by examining the Department of Neurosurgery database. A random cohort of 28 patients younger than 70 years of age (control group) was selected from the overall population of patients who underwent CFR. There were 28 patients ranging in age from 70 to 84 years (median 74 years). Major local complications occurred in seven elderly patients (25%) and in six control patients (21%) (p = 0.75), and major systemic complications occurred in nine elderly patients (32%) and in three control patients (11%) (p = 0.05). There was one perioperative death in both groups of patients. The median duration of disease-specific survival for the elderly patients was not reached (mean 6.8 years); however, it was 8.3 years for control patients (p = 0.24). Predictors of poorer overall survival from a multivariate analysis of the elderly group included presence of cardiac disease (p = 0.005), a major systemic perioperative complication (p = 0.03), and a preoperative Karnofsky Performance Scale score less than 100 (p = 0.04). CONCLUSIONS: In this study of elderly patients who underwent CFR, there was no difference in disease-specific survival when compared with a matched cohort of younger patients. There was, however, an increased incidence of perioperative major systemic complications in the elderly group.