ADVANCED ESOPHAGEAL-CARCINOMA

From 1976 until 1990 a total of 212 patients with squamous cell carcin oma of the thoracic esophagus were referred for surgical treatment. Re sectability was 84.1% (161 of 191). Actuarial 5-year survival in patie nts with negative lymph nodes was 51.2% versus 12.4% in lymph node-pos itive patients. Therefore advanced carcinoma was defined to compromise all patients with involved regional (N1) or distal lymph nodes (M(+Ly )) as well as patients with T4 tumors or solid organ metastasis (M(+or g)) irrespective of their lymph node status. Comparing complete (R(0)) versus incomplete (R(1)-R(2)) resections for stage III and IV carcino ma revealed 20% acid 0% five-year survivals, respectively. There was n o 5-year survival in the stage IV group. When excluding solid organ me tastasis, the median survival shifted from 8.5 months after incomplete (R(1)-R(2)) to 20 months after complete (R(0)) resection. In 1991 thr ee field lymphadenectomy was initiated that included bilateral cervica l lymphadenectomy. Thirty-seven patients have been treated so far (23 squamous cell carcinoma, 14 adenocarcinomas). Cervical lymph nodes wer e positive in 24.3% with an incidence up to 28.5% for distal-third car cinoma. Subsequently, 6 patients (16%) moved from MO to M(+Ly) status. Our results confirm the key role of surgery not only in improving sur vival and locoregional tumor control but in refining the accuracy of s taging advanced carcinomas provided complete resection is possible. No wadays other options in the treatment of advanced carcinoma are mainly based on neoadjuvant chemoradiotherapy with response rates ranging fr om 40% to 60% but until now without evidence of improved 5-year surviv al rates and with local or distant failure rates of approximately 30% and 45%, respectively. For clinically nonresectable (T4) or presumed n onresectable tumors, neoadjuvant therapy seems to have an important ro le, as it may convert these tumors into resectable and therefore poten tially curable cancers. Toxicity remains a drawback, as it is probably responsible for preoperative dropouts and slight but definitive highe r postoperative mortality and morbidity. When the disease clearly is i ncurable, the best options today are laser therapy and an endoprosthes is, which result in good relief of dysphagia in approximately 80% to 8 5% of patients and a procedure related mortality below 5%.