Small carcinoma of the pancreas. Clinical and pathologic evaluation of 17 patients

The clinical and pathologic characteristics of 17 small carcinomas (less than 2 cm in diameter) of the pancreas are reviewed in this article. All the tumors were located in the head of the pancreas, and the clue to the diagnosis was jaundice in ten patients and abdominal pain in seven. Carcinoembryonic antigen (CEA) and CA 19-9 were not reliable markers for detecting small carcinomas of the pancreas. Ultrasonography (US), computerized tomography (CT), percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangiopancreatography (ERCP) were useful diagnostic tools. Lymph node metastases were found in 41% of affected patients, capsular invasion in 24%, retroperitoneal invasion in 24%, and portal system involvement in 29%. In five patients the carcinoma was Stage I; in eight patients, Stage II; in two patients, Stage III, and in two patients, Stage IV. Fifteen patients with Stages I to III and one patient with Stage IV underwent curative pancreaticoduodenectomy or total pancreatectomy, and one patient with liver metastasis and Stage IV underwent noncurative pancreaticoduodenectomy. The cumulative 4-year survival rate was 37%. Although four patients with Stage I disease lived for more than 48 months, the survival period of the 12 patients with Stages II to IV disease was less than 25 months. Thus, small carcinoma of the pancreas is not always curable; however, a small, localized lesion without any extratumoral extension can be resected with a chance of cure.     

Radical pancreatectomy for ductal cell carcinoma of the head of the pancreas

Seventy-four patients were treated with a radical or a nonradical pancreatectomy for ductal cell carcinoma of the head of the pancreas. Their survival rates and the selection of the operative procedure were evaluated. In 32 patients, a radical pancreatectomy was attempted where there was sufficient clearance of regional or juxta-regional lymph nodes beyond the group of suspected metastatic nodes, as well as a resection of a greater margin of soft tissue around the pancreas. These patients' cumulative 5-year survival rate was 33.4%. In 14 Stage I or Stage II patients, the cumulative 5-year survival rate was 46.4%. In 18 Stage III or Stage IV patients, the cumulative 5-year survival rate was 20.7%. For 42 patients treated with a nonradical pancreatectomy with the dissection of lymph nodes adjacent to the pancreas or of regional lymph nodes but with insufficient clearance of the soft tissue around the pancreas, the cumulative 2-year and 3-year survival rates were 5.4% and 0%, respectively. In seven patients with Stage II carcinoma, the survival rate was 16.7% after 2 years and 0% after three years. In 35 Stage III or Stage IV patients, the survival rate was 3.2% after 2 years and 0% after 3 years. Thus, the survival rates were significantly higher in patients treated with radical operation than in patients who had nonradical operation. These results indicate that a radical pancreatectomy with sufficient lymph node clearance with the surrounding connective tissue around the pancreas is indispensable to cure patients with ductal cell carcinoma of the pancreas.     

178例胰头癌的诊治分析

目的：分析胰头癌的临床表现,诊治方法,提高胰头癌的诊治水平。方法：用回顾性方法研究178例胰头癌的临床表现,诊治方法及治疗效果。:结果：178例患者主要临床表现有上腹部疼痛及不适,占69．7％;梗阻性黄疸,占74．2％,这两各症状1、Ⅱ期与Ⅲ、Ⅳ期之间差异均有显著性（P＜0．001）,伴腰背部疼痛者占17．9％,其中IV期占81．3％,对胰头肿瘤检出率B超为74．2％,CT为87．3％,MRI为85．5％,全组行根治性胰十二指肠切除术18例（10．1％）,术后1,3,5,年生存率分别为67．5％,36．0％和5．6％,胆汁内引流术115例。肿瘤未切除而行放、化疗者,中位生存期为7个月,结论：上腹疼痛不适及梗阻性黄疸为胰头癌的常见症状,高血糖为多发合并症,腰背疼痛常为晚月。结论：上腹疼痛不适及梗阻性黄为胰头癌的常见症状,高血糖为多发 合并症,腰背疼痛为晚期表现,CT是最重要的影像学诊断方法,B超,CT和（或）MRI联合检查可提高诊断率（达96．6％）,目前,胰十二指肠切除术是胰头癌唯一有效的治疗方法,胆汁内引流是重要的姑息治疗方法。     

Biliary and duodenal bypass for carcinoma of the head of the pancreas

A review was undertaken of 66 patients having palliative bypass surgery for carcinoma of the head of the pancreas. A second laparotomy for relief of duodenal obstruction was necessary in six of 29 (20%) of the patients who did not have gastroenterostomy performed initially, but late gastric outlet obstruction occurred only once in 37 patients having an initial gastroenterostomy (P less than 0.05). Cholecystojejunostomy failed to provide permanent biliary bypass in 14 of 53 (26%) patients, compared to successful drainage in all 13 patients having anastomosis of the common hepatic duct to the jejunum (P less than 0.05). In seven patients cholecystojejunostomy was performed when the cystic duct was already obstructed by tumour. Therefore prophylactic gastrojejunostomy is recommended as a routine. The gallbladder should only be used for biliary bypass when appropriate contrast x-rays have demonstrated the patency of the cystic duct.     

The continuing problem of carcinoma of the pancreas

The courses of 208 patients with adenocarcinoma of the pancreas were reviewed. The lesion was located in the head of the pancreas in 142 patient, (68%) and of these, in 22 patients the diagnosis was confirmed histologically at postmortem examination; 21 patients underwent laparotomy and biopsy with a 33% operative mortality and a 3.4-month average survival; 89 patients underwent biliary and/or gastric bypass with a 24% mortality and 4.8-month average survival; 10 patients underwent pancreaticoduodenectomy with a 20% mortality and 14.6-month average survival. The lesion was located in the body or tail of the pancreas in 77 patients (32%); and, of these, 15 patients had histologic confirmation of clinical diagnoses at postmortem examination; 19 patients underwent biopsy of extra-abdominal metastases and survived an average of 1.4 months; 27 patients underwent laparotomy and biopsy with a 26% operative mortality and 3.5-month average survival; 4 patients underwent gastric and/or biliary bypass with a 50% mortality and 4.5-month average survival; one patient underwent noncurative distal pancreatectomy and survived 1 month postoperatively. No patient was cured of his disease. Of the 55 operative survivors of biliary bypass alone for carcinoma of the head of the pancreas, 5 (9%) required subsequent gastroenterostomy for duodenal obstruction.     

胰头癌手术切除可能性的术前评价

目的通过总结胰头癌病人的临床表现和影象学检查结果来评价手术切除的可能性。方法总结32例胰头癌病人的临床表现和CT、磁共振（MRI）检查结果,判断肿瘤是否已发生邻近浸润或远处转移,以此来评价其手术切除的可能性。结果在22例作CT检查的病例中,判断正确的为17例,准确率为77．3%。作MR检查9例,全部判断正确,准确率为100%。结论某些特殊的临床表现和CT、MR检查对判断肿瘤是否发生邻近浸润或转移有较大价值,为术前评价手术切除的可能性提供依据。     

Clinical significance of midkine expression in pancreatic head carcinoma

Midkine (MK) is a heparin-binding growth factor and a product of a retinoic acid-responsive gene. Midkine is overexpressed in many carcinomas and thought to play an important role in carcinogenesis. However, no studies have been focussed on the role of MK in pancreatic carcinoma. This study sought to evaluate the clinical significance of MK expression in pancreatic head carcinoma, including the relationship between immunohistochemical expression and clinicopathologic factors such as prognosis. Immunohistochemical expression of MK and CD34 was evaluated in pancreatic head carcinoma specimens from 75 patients who underwent surgical resection. Midkine was expressed in 53.3% of patients. Midkine expression was significantly correlated with venous invasion, microvessel density, and liver metastasis (P=0.0063, 0.0025, and 0.0153, respectively). The 5-year survival rate was significantly lower for patients positive for MK vs patients negative for MK (P=0.0073). Multivariate analysis revealed that MK expression was an independent prognostic factor (P=0.0033). This is the first report of an association between MK expression and pancreatic head carcinoma. Midkine may play an important role in the progression of pancreatic head carcinoma, and evaluation of MK expression is useful for predicting malignant properties of pancreatic head carcinoma.     

The intraductal carcinoma component is a significant prognostic parameter in patients with invasive ductal carcinoma of the pancreas.

We have sometimes encountered invasive ductal carcinomas (IDCs) of the pancreas containing intraductal carcinoma components in the intra- and / or extra-tumor area. The purpose of this study was to investigate whether intraductal carcinoma components would be useful for predicting the outcome of IDC patients. Forty-seven surgically treated IDCs were examined, and all histological tumor sections were stained with Elastica to accurately confirm intraductal carcinoma components. Well-known clinicopathological parameters that exhibited a significant correlation in the univariate analyses for predicting disease-free survival (DFS) and overall survival (OS) were entered into the Cox proportional hazard multivariate analysis. Since the lowest P-value predicting DFS or OS periods was observed in IDCs with more than 10% intraductal carcinoma components and those with 10% or less intraductal carcinoma components (P = 0.028 and P = 0.019), we established the cutoff value of intraductal carcinoma components at 10%. In the multivariate analyses for DFS and OS, the presence of more than 10% intraductal carcinoma components showed a marginally significant increase in the hazard rate (HR) of tumor recurrence (P = 0.067) and significantly increased the HR of mortality (P = 0.040). The present study demonstrated that IDCs with more than 10% intraductal carcinoma components were associated with a significantly better patient outcome than those with 10% or less intraductal carcinoma components.     

Adenosquamous carcinoma of the pancreas: a clinicopathologic study

A total of eight patients with adenosquamous carcinoma of the pancreas were studied clinicopathologically. Histochemical and immunohistochemical studies were also done. The 8 patients were composed of 4 men and 4 women with a mean age of 56 years, which was 9 years younger than for other pancreatic carcinoma. The site of origin and size of the tumors were similar to those of usual pancreatic carcinoma. Histopathologically, all eight tumors showed an abrupt transition between adenocarcinoma and squamous cell carcinoma. Squamous cell carcinoma was located at the periphery of the tumors. Histochemistry and immunohistochemistry disclosed a different nature for both components. The cumulative 1-year survival rate of the 8 patients was 21.4%, compared to 42.1% of 72 with adenocarcinoma of the pancreas. The survival curve of the 8 patients with adenosquamous carcinoma was significantly less favorable than that of 36 patients with well-differentiated adenocarcinoma of the pancreas. These facts support the view that squamous cell carcinoma in adenosquamous carcinoma of the pancreas is squamous cell metaplasia of the pre-existing adenocarcinoma. The clinical course of adenosquamous carcinoma of the pancreas was unfavorable.     

Factors influencing survival after resection for ductal adenocarcinoma of the head of the pancreas

BACKGROUND AND OBJECTIVES: Recent reports have demonstrated improvement in the 5-year actuarial survival for patients with resected ductal adenocarcinoma. The purpose of this study is to determine the factors favoring long-term survival after pancreaticoduodenectomy. METHODS: Between 1974 and 1995, 75 patients with pancreatic head carcinoma underwent pancreaticoduodenectomy in our department. RESULTS: Overall postoperative mortality rate was 5. 3% and morbidity was 24%. Median survival following resection was 17 months. Estimated 1-, 2-, and 5-year survival rates were 68%, 46.7%, and 18.7%, respectively. Five-year survival was greater for node-negative than for node-positive patients (41.7% vs. 7.8%, P < 0. 001) and for smaller (<3 cm) than for larger tumors (33.3% vs. 8.8%, P < 0.006). The 5-year survival in patients with negative margins (n = 60) was 23.3%, whereas no patient with positive margins (n = 15) survived at 13 months (P < 0.001). Multivariate analysis, performed by the Cox proportional hazards model, indicated that margin status, lymph node metastasis, tumor size, and poor histological differentiation were independent predictors of poor survival. CONCLUSIONS: Five-year survival for patients undergoing pancreaticoduodenectomy for ductal adenocarcinoma of the pancreas was 18.7%. Survival was greater in the group of patients with negative lymph nodes, tumor size <3 cm, and negative margin status.     

The alternation of peripheral lymphocyte subsets in head and neck carcinoma

Peripheral lymphocyte subsets of 115 patients with head and neck carcinomas were examined by the monoclonal antibody technique. In fresh tumor-bearing, the OKT 4 rate was decreased (P less than 0.01) and the OKT 8 rate was increased (P less than 0.05). Consequently the OKT4/OKT8 ratio was decreased (P less than 0.01) compared with normal healthy individuals. This result shows the abnormality of cellular immunity in carcinoma cases. The OKT4/OKT8 ratio reflected the clinical stages and courses sufficiently and correlated with other immunological parameters. The OKT4/OKT8 ratio is considered to be one of the parameters for elucidating the clinical conditions and immunities of carcinoma patients.     

The ribosomal P0 protein induces a spontaneous immune response in patients with head and neck advanced stage carcinoma that is not dependent on its overexpression in carcinomas

A typical feature in systemic lupus erythemathosus patients is the presence of autoantibodies to the carboxyl-terminal homologous P proteins (P0, P1, P2) domain (C-22 P0 epitope). In this report we provide evidence for the in vivo immunogenicity of the P0 protein in head and neck cancer patients as well as overexpression by immunohistochemistry of the C-22 P0 epitope in invasive carcinomas (55/57). Overexpression of this epitope was also significantly associated with a number of pathological lesions arising in the head and neck stratified epithelium including acanthosis (8/8), benign tumors (11/11), dysplasia (23/25) and in situ carcinomas (9/9). Intermediate cell layer restricted epitope overexpression was observed in well differentiated carcinomas, while undifferentiated tumors showed overexpression throughout the cell layers. Employing recombinant P proteins, sera from 40 of the 57 carcinoma patients and 39 normal donors, were subjected to immunoblot analysis. Immunity to P0 protein (7/40) was associated with malignancy and with advanced disease stage, but it was not dependent on the C-22 P0 epitope overexpression, although it was the preferential autoantibody target in 4 patients. Increased expression of the C-22 P0 epitope on the surface of pharynx cancer cells following cellular stress in vitro, may imply P0 protein presentation as an in vivo autoantibody target in cancer patients. Evidence for immunity to the P0 protein, as well as overexpression in patients with head and neck carcinoma may be relevant for monitoring cancer progression, in planning immunotherapeutic strategies, and contribute to the understanding of immuno-biological behaviour of head and neck carcinomas.     

Influence of Hispanic ethnicity on outcome after resection of carcinoma of the head of the pancreas

BACKGROUND: Poor outcomes in Hispanic patients have been reported for tumors at a number of sites. The authors sought to determine whether a similar phenomenon occurs in Hispanics after the resection of solid epithelial tumors of the head of the pancreas. METHODS: Between 1983-1995, 273 patients with noncystic epithelial carcinoma of the head of the pancreas were evaluated. Resection was accomplished in 104 patients (38%); these patients were the focus of the current retrospective review. Of the patients who underwent resection, 26 (25%) were Hispanic and 78 (75%) were non-Hispanic. RESULTS: Although Hispanic patients tended to present at a significantly younger age and their serum bilirubin level was significantly higher, no other differences in clinical characteristics were observed. After resection, Hispanic patients had a median survival of only 11.4 months, whereas the non-Hispanic group had a median survival of 21.7 months (P = 0.009). Hispanic ethnicity, as well as age > 74 years and jaundice at the time of presentation also were found to be significant prognostic factors on multivariate analysis. Hispanic patients did not present with more advanced disease and no delays in assessment by a physician or in proceeding to surgery were observed. Furthermore, the rate of resection was the same in Hispanic patients and non-Hispanic patients. Long-term survival after palliative bypass was similarly worse in the Hispanic subgroup. CONCLUSIONS: Hispanic patients treated at the study center appeared to have a diminished survival after resection of a tumor of the head of the pancreas. No treatment-related factors were identified that could explain this discrepancy in outcome.     

Subtotal duodeno-pancreatectomy for carcinoma of the head of the pancreas. Preliminary report of an alternative operation to total pancreatectomy

For ductal carcinoma of the head of the pancreas and large periampullary carcinoma with wide infiltration into the head of the pancreas a subtotal duodeno-pancreatectomy with preservation of the pancreatic tail and spleen is introduced as an alternative to total pancreatectomy. A preliminary report of 38 operations shows a mortality of only 3% and a low morbidity. Diabetes mellitus increased from 17% preoperatively to 40% postoperatively, therefore, in 60% a normal carbohydrate metabolism was preserved. At present 5 of 20 patients (R0) with ductal cancer are alive and free of recurrence 18 to 55 months after the operation with a median survival of 12 months for all curatively resected patients. No negative influence on median survival time can yet be recognized. Subtotal duodeno-pancreatectomy was performed with a much lower operative risk than total pancreatectomy and seems to be as effective as total organ removal.     

Lymphatic flow in carcinoma of the head of the pancreas.

The lymphatic pathway from the head of the pancreas to the para-aortic lymph nodes was examined on the basis of the frequency of lymph node involvements. Forty-four patients were examined. All patients had extended radical operations. Thirty-one of 44 (70.5%) patients had lymph node involvement. The lymph nodes that had a high metastatic rate included the following: (1) lymph nodes around the common hepatic artery (number 8 lymph node); (2) lymph nodes of the hepatoduodenal ligament (number 12 lymph node); (3) the posterior pancreaticoduodenal lymph node (number 13 lymph node); (4) lymph nodes around the superior mesenteric artery (number 14 lymph node); (5) para-aortic lymph nodes (number 16 lymph node); and (6) the anterior pancreaticoduodenal lymph node (number 17 lymph node). Twenty-eight of these 31 patients had disease in the posterior pancreaticoduodenal lymph node. The patterns of lymph node involvement consisted of four combinations: number 13-number 17, number 13-number 14, number 14-number 16, and number 17-number 8. All of the patients with number 16 nodal involvement had number 14 lymph node metastasis. However, there was no relationship between tumor size and lymph node involvement. Based on these results, the main lymphatic pathway from the head of the pancreas to the para-aortic lymph nodes was thought to be via the lymph nodes around the superior mesenteric artery, assuming that lymphatic flow is anterograde. In addition, this study demonstrates that it is necessary to perform an extensive lymph node dissection, including the para-aortic lymph node, even in patients with small tumors.     

Morphological patterns of primary nonendocrine human pancreas carcinoma.

The study of histological sections of 406 cases of nonendocrine pancreas carcinoma at Memorial Hospital indicated that morphological patterns of pancreas carcinoma could be delineated as follows: duct cell adenocarcinoma (76%), giant-cell carcinoma (5%), microadenocarcinoma (4%), adenosquamous cancinoma (4%), mucinous adenocarcinoma (2%), anaplastic carcinoma (2%), cystadenocarcinoma (1%), acinar cell carcinoma (1%), carcinoma in childhood (under 1%), unclassified (7%). In 195 cases of patients with pancreas carcinoma, search was made for changes in the pancreas duct epithelium and these were compared to duct epithelium in a control group of 100 pancreases from autopsies of patients with nonpancreatic cancer. The following incidences were found for pancreas cancer and nonpancreatic cancer, respectively: mucous cell hypertrophy, 39 versus 28%; pyloric gland metaplasia, 28 and 17%; epidermoid metaplasia, 6 and 12%; papillary hyperplasia, 42 and 12%; atypical duct hyperplasia, 14% and none; cancinoma in situ in 19% and none in the control group. Mucin in the majority of pancreas cancers suggested that the cell type of origin of the common pancreas cancer is the mucin-producing duct epithelium. The association of atypias and carcinomas in situ in the patients with pancreas carcinoma implies, by analogy to other organs, that there may be a significant latent period between the appearance of carcinoma in situ and the grossly recognizable pancreas cancer.     

无功能胰岛细胞肿瘤的诊断与治疗

目的分析无功能胰岛细胞肿瘤(NFICCs)的临床病理特征,探讨其临床诊治方法。方法回顾性分析43例无功能胰岛细胞肿瘤的临床、病理及预后资料。采用Kaplan-Meier生存曲线分析及Log rank统计分析。结果43例无功能胰岛细胞肿瘤患者中,无功能胰岛细胞癌(NFICC)28例,无功能胰岛细胞瘤(BNFICTs)15例。临床症状以腹痛、恶心、呕吐、乏力及腹部肿块多见。术前B超及CT均能确定胰腺肿块。肿瘤位于胰头部21例,胰尾部10例,胰体部6例,体尾部5例,多发性1例。全组总的手术切除率为90.7%,根治切除率为69.8%,姑息手术20.9%。NFICC患者手术切除率及根治性切除率分别为78.6%和60.7%。NFICC患者的5年及10年生存率分别为58.1%和29.0%。女性、30岁以下、根治性手术以及肿瘤直径<10 cm的患者预后较好。多因素回归分析证实,手术方法是惟一的预后影响因素(P=0.007)。结论无功能胰岛细胞肿瘤好发于年轻女性,手术切除率较高。患者采取手术治疗、特别是根治性手术,可以获得较理想的远期疗效。     

扩大淋巴结清扫对胰头癌患者预后效果的观察

目的 探讨扩大淋巴结清扫对胰头癌患者疗效及预后的影响.方法 回顾性分析136例胰头癌患者的临床资料,根据治疗方法的不同将患者分为扩大组和常规组,每组各68例.常规组患者接受胰十二指肠切除术及常规淋巴结清扫,扩大组患者接受胰十二指肠切除术及扩大淋巴结清扫.比较两组患者的术中、术后指标及并发症发生率.结果 扩大组患者的手术时间长于常规组,术中出血量多于常规组(P﹤0.05).扩大组患者术后胃排空延迟的发生率高于常规组,阳性淋巴结检出数多于常规组,原位癌复发率低于常规组,差异均有统计学意义(P﹤0.05).术后两组患者吻合口瘘、腹腔出血及腹腔感染的发生率比较,差异均无统计学意义(P﹥0.05).随访5~33个月,两组患者的中位生存时间比较,差异无统计学意义(P﹥0.05).结论 对于行胰十二指肠切除术的胰头癌患者,扩大淋巴结清扫范围可提高阳性淋巴结检出率,降低原位癌复发率,但对患者的远期疗效无明显影响,同时加重了对患者机体的损伤,延长了手术时间,增加了术中出血量及胃排空延迟的发生率,不建议常规对患者采用扩大淋巴结清扫术,尤其是年老及身体状况较差者.     

Pancreatoduodenal carcinoma: a clinicopathologic study of 304 patients and immunohistochemical observation for CEA and CA19-9

A total of 304 patients with pancreatoduodenal carcinoma were studied clinicopathologically and immunohistochemically in order to clarify features of carcinoma of four different sites of origin; carcinoma of the ampulla of Vater (Am), the distal common bile duct (DCBD), the head of the pancreas (PH), and the extra-ampullary duodenum (Du). The mean greatest diameter of 87 PH was 3.5 cm compared with 2.7 cm of 149 Am and 2.7 cm of DCBD. Histopathologically, 40% of Am were papillary adenocarcinoma, while about half of DCBD, PH and Du were tubular adenocarcinoma. PH invaded lymphatic (85%), vascular (62%), and perineural (95%) spaces and metastasized lymph nodes (72%) more frequently than Am (77%, 35%, 24%, 50%), DCBD (47%, 61%, 65%, 45%), and Du (76%, 29%, 35%, 65%), respectively. More than 50% of PH invaded the resected margins, whereas in only 2% of Am, the surgical margins were affected by malignant cells. Immunohistochemically, PH was more frequently positive for both carcinoembryonic antigen (CEA) (98%) and carbohydrate antigen (CA) 19-9 (91%) than Am (83%, 62%), DCBD (94%, 58%), and Du (56%, 11%), respectively. The stromal staining type of CEA and CA 19-9 was more frequently seen in PH (27%, 44%) than in Am (9%, 31%), DCBD (11%, 8%) and Du (0%, 0%), showing a more dedifferentiated nature of PH. The cumulative 3-year survival rate of 87 patients with PH (15%) was worse than that of 149 with Am (42%, P less than 0.001), of 51 with DCBD (25%) and of 17 with Du (58%, P less than 0.001). The survival curve of 87 with PH was worse than that of 51 with DCBD, of 149 with Am (P less than 0.001) and of 17 with Du (P less than 0.001). Cox regression analysis, using eleven profound prognostic variables, revealed that venous invasion, perineural infiltration, surgical margin, and histopathologic type were profound prognostic factors. Pancreatic carcinoma has a more dedifferentiated histopathologic nature, showing a more aggressive growth and fares worse than Am, DCBD, and Du.     

Limited resection for carcinoma of the upper thoracic oesophagus is not a realistic option.

AIMS: Due to its anatomical position, carcinoma of the proximal oesophagus results in early invasion of adjoining structures, often precluding (radical) resection. We performed a retrospective study to compare the potentially curative and palliative treatment results in patients with proximal (i.e. at or above the carina) vs distal oesophageal carcinoma. METHODS: Over a 3-year period 30 patients with proximal and 145 patients with distal oesophageal cancer underwent surgery. RESULTS: Microscopically radical resection was achieved in 11/30 patients (43%) with a proximal tumour and in 96/145 patients (66%) with a distal tumour (P=0.007). Three-year survival was 13.8%vs 44.3% respectively; localization was an independent prognostic factor. Recurrent upper aero-digestive tract symptoms developed in 38% of the patients with a proximal tumour and in 19% of the patients with distal carcinoma (P<0.05). DISCUSSION: Carcinoma of the proximal oesophagus has a worse prognosis than more distal carcinomas. Definite cure is exceptional; many patients are ineffectively palliated. In patients with proximal oesophageal carcinoma surgery should not be performed outside clinical trials testing multimodality treatment.