Esophageal carcinoma. The value of staging in long-term survival.

A three-stage study of 177 patients in Puerto Rico who had esophageal carcinoma is presented. Those surviving five or more years over a twenty-one-year period were located. Next, the experience at the San Juan City Hospital from 1968 to 1973 was examined. The information obtained from those two groups led to the last stage, a prospective study in which treatment was based on objective staging of the extent of the disease. Only 27% of these patients are really potentially curable upon admission to the hospital, and they should have aggressive therapy. Adequate palliation can be obtained with radiotherapy and chemotherapy in the remainder. The findings that nearly half of the five-year survivors had metastases or tumor extension and that some patients survived for prolonged periods without treatment emphasize the need for individualized treatment and research in tumor immunology.     

Long-term survival after resection for bronchogenic carcinoma.

Of 915 resections for bronchogenic carcinoma over a 25-year period (1945-1969), 249 patients survived over 5 years; 127 of the patients eligible survived over 10 years, 61 over 15 years, and 22 over 20 years. The case material was divided into three time periods: 1945-49, 1950-59 and 1960-69, as well as by extent of resection. Lobectomy became the operation of choice, pneumonectomy being reserved for the more extensive lesions. Observed survival rates at 5, 10 and 15 years for 561 patients in the lobetomy series were 35, 22 and 15%, respectively, but strikingly increased to 41, 28 and 19% in the 1960-69 period. Observed rates for 354 patients having pneumonectomies were similar for three time periods, being 16, 8 and 6% at 5, 10 and 15 years, respectively. Relative survival rates for the lobectomy series at 5, 10 and 15 years rose from 33, 28 and 26%, repectively, in the 1950-59 period to 50, 39 and 35% in the last time period, becoming a near horizontal curve segment after 5 years. Dominant factors in survival were extent of the lesion and stage of nodal involvement, histologic type and location being less significant.     

Improved survival with neoadjuvant therapy and resection for adenocarcinoma of the esophagus.

OBJECTIVE: This study sought to determine the impact of preoperative chemotherapy and radiation therapy (neoadjuvant therapy) followed by resection in patients with adenocarcinoma of the esophagus. SUMMARY BACKGROUND DATA: Long-term survival in patients with carcinoma of the esophagus has been poor. An increase in the incidence of adenocarcinoma of the esophagus has been reported recently. METHODS: Fifty-eight patients with biopsy-proven adenocarcinoma of the esophagus treated at this institution from January 1951 through February 1993 were studied. Since 1989, 24 patients were entered prospectively into a multimodality treatment protocol consisting of preoperative cisplatin, 5-fluorouracil (5-FU), and leucovorin with or without etoposide, and concomitant mediastinal radiation (30 Gy). Patients were re-evaluated and offered resection. RESULTS: There were no deaths related to neoadjuvant therapy and toxicity was minimal. Before multimodality therapy was used, the operative mortality rate was 19% (3 of 16 patients). With multimodality therapy, there have been no operative deaths (0 of 23 patients). The median survival time in patients treated before multimodality therapy was 8 months and has yet to be reached for those treated with the neoadjuvant regimen (> 26 months, p < 0.0001). The actuarial survival rate at 24 months was 15% before multimodality therapy and 76% with multimodality therapy. No difference in survival was noted in neoadjuvant protocols with or without etoposide (p = 0.827). CONCLUSIONS: Multimodality therapy with preoperative chemotherapy and radiation therapy followed by resection appears to offer a survival advantage to patients with adenocarcinoma of the esophagus.     

Radical resection improves survival for patients with pT2 gallbladder carcinoma.

Radical resection (wedge resection of the gallbladder bed and dissection of the hepatoduodenal ligament, portal, and celiac lymph nodes) has been reported to improve survival from pathologic T2 gallbladder carcinoma (pT2 GBCa; invasion through the muscularis without perforation of the serosa). We report our experience and the outcome of patients with pT2 GBCa. Between 1989 and 2000 at Vanderbilt University Medical Center ten patients were found to have pT2 disease after cholecystectomy. The patients had an average age of 64+/-13 years and underwent either radical resection (n = 5) or no further surgical therapy (n = 5). Of the patients who underwent cholecystectomy only, one (20%) is still alive at 27 months and four (80%) died of recurrent GBCa between 6.5 and 21 months. For the patients who underwent radical resection all five are alive at 15 to 83 months with no recurrence. The proportion of patients surviving pT2 GBCa after radical resection was significantly greater than with cholecystectomy alone (P < 0.05). The difference in length of survival between the two groups was also significant (P < 0.05). Morbidity after radical resection was low (pancreatic leak in one patient), and there were no operative mortalities. Radical resection significantly improved survival over cholecystectomy alone for patients with pT2 GBCa. The procedure has low morbidity and mortality rates. Therefore a radical resection operation is indicated for patients with pT2 GBCa.     

Improved survival after resection of colorectal liver metastases

Background: The goal of this study was to determine if staging with intraoperative ultrasound (IOUS), assessment of porta hepatis lymph nodes, and evaluation of resection margins can improve selection of patients likely to benefit from resection of colorectal liver metastases. Methods: A retrospective evaluation was performed on patients undergoing celiotomy with intent to resect colorectal liver metastases. Patients were considered unresectable if extrahepatic disease was identified by peritoneal exploration or if IOUS demonstated greater than four lesions or the inability to achieve negative margins. Tumor-negative margins were confirmed by pathologic evaluation. Actuarial 5-year survival was calculated using the method of Kaplan and Meier. Results: Median follow-up is 25 months. Of the 151 patients undergoing operative exploration, 107 (71.0%) underwent liver resection (all margins tumor negative). Three operative deaths occurred in this group (2.8%). The disease of 30 patients (19.8%) was considered unresectable due to extrahepatic involvement, and that of 14 patients (9.2%) was demonstrated by IOUS to be unresectable. Five-year actuarial survival was 44% for the resected group and 0% for the unresectable patients (p<0.0001). Conclusions: IOUS, portal node assessment, and pathologic margin evaluation improves the selection of patients likely to benefit from resection of colorectal liver metastases. Presented at the 47th Annual Cancer Symposium of The Society of Surgical Oncology, Houston, Texas, March 17–20, 1994.     

Congenital aortic valve disease. Improved survival and quality of life.

OBJECTIVE: The purpose of the study was to assess the effect of recent trends in surgical management, including use of the Ross Operation, on improved survival and quality of life in patients treated surgically for aortic valve (AV) disease at Oklahoma Children's Hospital. BACKGROUND: Surgical treatment of congenital AV disease has proved to be palliative, but newer procedures may be improving outcomes. METHODS: A retrospective review of 301 patients, age 1 day to 26 years (median, 5 years), having a surgical AV procedure or aortic balloon valvuloplasty at Children's Hospital of Oklahoma between 1960 and February 1996, was conducted. Information was collected on all prior and subsequent operations, and follow-up within 1 year was 96% complete. RESULTS: Survival for all patients was 90% +/- 2% at age 10 years and 73% +/- 8% at age 25. By age 5, 52% +/- 4% had required an AV procedure, 89% +/- 3% by age 15. Patient survival was affected adversely by the diagnosis of valvar aortic stenosis, 79% +/- 6% at age 25 compared to 95% +/- 4% for subvalvar aortic stenosis or aortic insufficiency (p = 0.01). The AV morphology did not affect survival, but patients with a bicuspid or unicuspid valve required operative intervention at an earlier age. Survival after autograft replacement of the AV (Ross Operation) was significantly better than for other types of valve replacement (p = 0.0043). Quality of life as assessed by need for reoperation favors the use of the Ross Operation, with freedom from reoperation at 9 years of 87% +/- 7% compared to 55% +/- 5% in all patients after first AV surgery (p = 0.003). CONCLUSIONS: The Ross Operation appears to have a significant advantage in survival and quality of life in children requiring a valve replacement as a first operation or after a prior AV procedure.     

Improved survival in carcinoma of the nasopharynx

Between 1970 and 1980, we treated 107 previously untreated patients with biopsy-proven carcinoma of the nasopharynx by megavoltage external radiation therapy to the primary site, base of the skull, and both sides of the neck. Eighty-seven percent of the patients had stage IV disease (American Joint Committee 1980), 53% had T4 primaries, and 73% had palpable cervical metastases. The histology was anaplastic or poorly differentiated carcinoma in 81%. The observed 5-year survival rate was 35% for the patients treated between 1970 and 1976, and increased to 72% for those treated between 1977 and 1980 (P less than 0.01). The two patient populations were similar except that the dose of irradiation (median and modal) to the primary site was 6,000 rad during 1970-1976 and 7,000 rad during 1977-1980. The survival rate was not significantly influenced by age, sex, birthplace, histology, or stage. These data suggest that a relatively high cure rate might be possible in carcinoma of the nasopharynx, even though most patients present with locally advanced disease. The patterns of relapse are discussed.     

Improved survival with adjuvant immunotherapy after surgical resection in a murine model

Background: Adoptive immunotherapy has met with limited success in the treatment of bulky metastatic disease. The purpose of this study was to determine whether lymphocytes stimulated in vitro could improve survival when given as an adjuvant to surgical resection in animals harboring microscopic metastatic disease. Methods: Lymphocytes from nodes draining the primary tumor (DLN lymphocytes) were stimulated in vitro with phorbol 12,13-dibutyrate and ionomycin and used as adjuvant immunotherapy after surgical resection of the primary tumor. Mice with advanced P-815 footpad tumors and disseminated microscopic metastases underwent amputation of the tumor-bearing extremity and were randomized to various adjuvant treatments. Results: Mice treated with adjuvant immunotherapy using stimulated DLN lymphocytes demonstrated significantly improved survival, showing that DLN lymphocytes stimulated in vitro can abrogate metastases that are invading multiple organs simultaneously. Mice successfully treated with adjuvant immunotherapy demonstrated long-term (80 days) in vivo antitumor activity by rejecting subsequent tumor challenge. In addition, stimulated DLN lymphocytes provided in vivo antitumor activity to naive mice. Conclusions: Adjuvant immunotherapy after resection in the face of residual microscopic tumor burden may prove to be a useful application of adoptive immunotherapy. Presented at the 46th Annual Cancer Symposium of The Society of Surgical Oncology, Los Angeles, California, March 18–21, 1993.     

Esophageal resection for carcinoma in patients older than 70 years

Background A larger number of older patients are presenting as candidates for esophageal resection. An aggressive surgical approach in this population is controversial. Methods Four hundred thirteen patients with esophageal cancer who presented to Roswell Park Cancer Institute from 1991 to 1998 were retrospectively reviewed. Clinical data, perioperative details, and postoperative courses were compared for patients older and younger than 70 years. Results One hundred forty-seven patients (36%) were older than 70 years. Risk factors, clinical symptoms, histology, and stage at presentation were equivalent for both age groups. A higher percentage of patients <70 years were candidates for curative resection. There were no significant differences between groups for estimated blood loss, intraoperative transfusions, length of stay, overall morbidity, or mortality. Only postoperative myocardial infarction and atrial fibrillation were increased in the older group. Excluding stage IV disease, there was a significant and similar improvement in median survival after resection for patients both <70 years and >70 years. Conclusions In conclusion, esophageal cancer in older patients warrants surgical resection because the benefit to the patient is the same as it is for younger patients, without a significant increase in operative morbidity or mortality. Presented at the 54th Annual Meeting of the Society of Surgical Oncology, Washington, DC, March 15–18, 2001.     

Esophageal resection with fundus rotation gastroplasty

Esophageal resection with fundus rotation gastroplasty. Anastomotic failure after esophageal resection remains a surgical problem with high clinical relevance. Anastomotic failure can be attributed to tension at the anastomosis especially in cervical anastomoses, as well as a perfusion deficit due to resection of the arterial arcade along the gastric lesser curvature. We attributed the anatomical deficiencies of conventional gastroplasties by developing a technique, that utilizes the whole gastric fundus and maintains the arterial arcade along the gastric lesser curvature: fundus rotation gastroplasty. Experimentally those tubes are 20 % longer than conventional tubes according to Kirschner/Akiyama and twice as good perfused. Clinically low failure rates of 7 % for cervical and thoracic anastomoses are achieved.     

Prognosis and survival after radical resection of primary adenosquamous lung carcinoma.

OBJECTIVE: In order to evaluate the follow-up study of surgical treatment for primary adenosquamous lung carcinoma (ASC) we specified prognostic criteria, also in comparison with primary adenocarcinoma (AC). METHODS: The study group consisted of 96 patients discharged between 1990 and 1999 after radical surgical treatment for ASC-80 (83%) men and 16 (17%) women aged 34-73, mean 56 years. Consequently, we evaluated 252 patients operated during the same time period for primary AC. RESULTS: Apart from grading, we did not find any significant differences between both ASC and AC groups of patients. Among the 96 patients operated radically for ASC median overall survival (OS) was 20 months. The cumulative postoperative survival rates at 5 and 10 years were 25.4 and 19.2%, respectively. By comparison, median OS for 252 patients with AC, discharged after surgical treatment in the same period, was 28.5 months and the cumulative postoperative survival rates at 5 and 10 years were 42.5 and 39.1%, respectively (P=0.006). At pathologic stages IA, the cumulative survival rate at 5 years was 63.3% for patients with ASC as compared with 72.1% for patients with AC (P=0.330). However, out of IB stage patients treated surgically for ASC 31.8% survived 5 years in comparison with 56.3% operated for AC (P=0.017). Study of survival rates did not differ significantly between ASC and AC patients at stage IIA (P=0.824) and stage IIB (P=0.217), respectively. Univariate analysis revealed that six factors of tumor size, T status, N status, as well visceral pleura involvement, tumor localization (central vs. peripheral) and tumor structure were significantly associated with the survival rate according to these variables. Multivariate analysis using Cox's proportional hazards model indicated that T factor, nodal involvement and one of the tumor components predominating were significant factors associated with the postoperative survival of patients with ASC. CONCLUSIONS: Our findings indicate that in patients after radical operation for ASC, predominance for one of the histopathological components (adenous or squamous) within primary tumor is attended by worst prognosis. Our study confirmed also that the prognosis of ASC of the lung was poorer than that of primary AC. Lack of generally accepted diagnostic criteria and unclear prognosis, even in the pathologic stage I suggest that there is a need for prospective studies in this respect.     

Esophageal carcinoma is frequently accompanied with early gastric carcinoma.

A review of data on 360 patients with esophageal squamous cell carcinoma who underwent esophageal resection revealed 14 cases (3.9%) and 16 lesions with synchronous gastric carcinomas. Among the 16 lesions, there were 14 (87.5%) early gastric carcinomas and two advanced carcinomas. Of the 14 early gastric carcinomas, two were minute (less than 5 mm in the largest diameter) early gastric carcinomas and four small (6-10 mm in the largest diameter). These gastric carcinomas were in a relatively early stage. The six early gastric carcinomas were not detected preoperatively. However, a thorough observation of the gastric mucosa could not be done in four of those due to stenosis which had developed as a result of the esophageal carcinoma. Therefore, intraoperative gastric observation should be done in cases in which the findings of the preoperative endoscopic examination of the stomach are inadequate and the upper gastrointestinal series reveal certain gastric abnormalities.     

Improved survival after resection of pulmonary metastases from malignant melanoma

The value of resecting pulmonary metastases from malignant melanoma was retrospectively examined. Between 1981 and 1989, 56 patients (35 men and 21 women with a mean age of 49 years) had 65 pulmonary resections for histologically proven metastatic melanoma after treatment of the primary tumor. In patients undergoing thoracotomy, 50% (28/56) had pulmonary metastases as the initial site of recurrence. Twenty-eight patients (50%) had local-regional recurrence before the development of lung metastases. Eight lobectomies, two segmentectomies, and 55 wedge excisions were done. Fifty-four patients (54/56, 96%) underwent complete resection, and there were no operative deaths. The postthoracotomy actuarial survival was 25% at 5 years (median interval, 18 months). Location of the primary tumor, histology, thickness, Clark level, local-regional lymph node metastases, or type of resection was not associated with improved survival. Patients without regional nodal metastases before thoracotomy had a median survival of 30 months compared with 16 months for all others (p = 0.04). Patients with lung as the site of first recurrence had a median survival of 30 months compared with 17 months for patients with initial local-regional recurrence (p = 0.038, log-rank test). Despite systemic spread, patients with isolated pulmonary metastases from melanoma may benefit from metastasectomy.