MANAGEMENT FOR PATIENTS WITH ADVANCED T4 EPIDERMOID CARCINOMA OF THE ESOPHAGUS

Available data concerning the treatment of patients with advanced T4 e sophageal carcinoma are limited. A consecutive series of 42 patients w ith advanced T4M0 epidermoid carcinoma of the esophagus were studied f rom June 1987 to July 1992. The aim of this study was to evaluate the efficacy of various therapeutic modalities, and further evaluate the t herapeutic options. The various therapeutic modalities included the fo llowing: Group I, feeding jejunostomy or endoesophageal intubation, 6 patients; Group II, palliative subtotal esophagectomy only, 8 patients ; Group III, bypass procedures without tumor resection, 9 patients; Gr oup IV, nutritional support and then treatment with irradiation (n = 8 ) or concurrent radio-chemotherapy (n = 4), 12 patients; Group V, subt otal esophagectomy, followed by aggressive concurrent radiochemotherap y, 7 patients. The total prescribed irradiation dose was 60 Gy (10 Gy/ 5 fractions/week). A combination regimen of chemotherapy consisted of cisplatin, 5-fluorouracil, and leucovorin (PFL regimen). For the patie nts undergoing esophagectomy or bypass procedures (n = 24), the rates of operative complication and mortality were 45.8% and 25%, respective ly. Side effects of adjuvant therapy (n = 24) consisted of main airway irritation (100%), mucositis or gastrointestinal symptoms (83.3%), he matologic toxicity (79.2%), esophagitis or gastric ulcer (62.5%), alop ecia (37.5%), and pneumonia (20.8%). The mortality due to toxicity of adjuvant therapy was 21.1% (4/19 patients). The mean survival times fo r each of the different groups was 1.9 +/- 0.5 months for Group I, 4.8 +/- 1.6 months for Group II, 5.2 +/- 1.2 months for Group III, 7.3 +/ - 2.0 months for Group IV, and 20.3 +/- 2.5 months for Group V, respec tively. Compared with patients of Groups I-IV, the Group V patients ha d a significantly superior one-year survival rate (P < 0.01). Our resu lts demonstrated that esophagectomy followed by concurrent irradiation and PFL combination chemotherapy may provide a significant improvemen t in the quality of life and survival for appropriate patients with ad vanced T4M0 epidermoid carcinoma of the esophagus. Furthermore, more t han one cycle of PFL regimen chemotherapy may result in a better progn osis. During the performance of such an aggressive treatment, the utmo st care must be taken with the patient's nutrition and to prevent pulm onary complications. (C) 1996 Wiley-Liss, Inc.