Preoperative low-dose weekly cisplatin and continuous infusion fluorouracil plus hyperfractionated radiotherapy in stage II-III esophageal carcinoma

BACKGROUND: The optimal regimen of preoperative chemoradiotherapy for resectable esophageal cancer has not been established. We evaluated accelerated hyperfractionated radiotherapy (RT) concurrent to low-dose weekly cisplatin and continuous infusion fluorouracil (LDCI-FU) followed by esophagectomy in patients with locally advanced squamous cell carcinoma (SCC) of the esophagus. METHODS: Patients with clinical stage II or III SCC of the esophagus received cisplatin 30 mg/m2/week (days 1, 8, 15), LDCI-FU 300 mg/m2/day (days 1-21), and concomitant RT to a dose of 45 Gy (150 cGy/fraction, 2 fractions/day) on tumor and affected lymph nodes, followed by radical esophagectomy. RESULTS: From 1997 to 2012, 64 patients were treated with this regimen. Twenty-four patients (37 %) had grade 3 esophagitis, 18 (28 %) of whom required hospitalization. The risk of hospitalization was reduced by placement of a jejunostomy tube before starting induction chemoradiotherapy. Six patients (9 %) had grade 3-4 neutropenia. Fifty-three patients (83 %) underwent esophageal resection and complete resection was achieved in 45 (70 %). The overall median survival was 28 months (95 % CI: 20.4-35.6) and 5-year survival was 38 %. In the 18 patients attaining a pathological complete response, median survival was 132 months and 5-year survival was 72 %. Positron emission tomography standardized uptake values (PET SUVmax) post-chemoradiotherapy were associated with pathological response (p = 0.03) and survival (p = 0.04). CONCLUSIONS: Intensive preoperative hyperfractionated RT concomitant to low-dose cisplatin and LDCI-FU is effective in patients with locally advanced SCC of the esophagus, with good pathological response and survival and manageable toxicities. Post-chemoradiotherapy PET SUV max shows promise as a potential prognostic factor

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Preoperative low-dose weekly cisplatin and continuous infusion fluorouracil plus hyperfractionated radiotherapy in stage II-III esophageal carcinoma.

BACKGROUND: The optimal regimen of preoperative chemoradiotherapy for resectable esophageal cancer has not been established. We evaluated accelerated hyperfractionated radiotherapy (RT) concurrent to low-dose weekly cisplatin and continuous infusion fluorouracil (LDCI-FU) followed by esophagectomy in patients with locally advanced squamous cell carcinoma (SCC) of the esophagus. METHODS: Patients with clinical stage II or III SCC of the esophagus received cisplatin 30 mg/m2/week (days 1, 8, 15), LDCI-FU 300 mg/m2/day (days 1-21), and concomitant RT to a dose of 45 Gy (150 cGy/fraction, 2 fractions/day) on tumor and affected lymph nodes, followed by radical esophagectomy. RESULTS: From 1997 to 2012, 64 patients were treated with this regimen. Twenty-four patients (37 %) had grade 3 esophagitis, 18 (28 %) of whom required hospitalization. The risk of hospitalization was reduced by placement of a jejunostomy tube before starting induction chemoradiotherapy. Six patients (9 %) had grade 3-4 neutropenia. Fifty-three patients (83 %) underwent esophageal resection and complete resection was achieved in 45 (70 %). The overall median survival was 28 months (95 % CI: 20.4-35.6) and 5-year survival was 38 %. In the 18 patients attaining a pathological complete response, median survival was 132 months and 5-year survival was 72 %. Positron emission tomography standardized uptake values (PET SUVmax) post-chemoradiotherapy were associated with pathological response (p = 0.03) and survival (p = 0.04). CONCLUSIONS: Intensive preoperative hyperfractionated RT concomitant to low-dose cisplatin and LDCI-FU is effective in patients with locally advanced SCC of the esophagus, with good pathological response and survival and manageable toxicities. Post-chemoradiotherapy PET SUVmax shows promise as a potential prognostic factor.

Tratamiento quirúrgico de la acalasia: estudio comparativo entre la cirugía abierta y la laparoscópica / Surgical treatment of achalasia: comparison between open and laparoscopic surgery

Introducción. La miotomía quirúrgica es una eficaz alternativa al tratamiento médico o endoscópico de la acalasia, especialmente en pacientes jóvenes o ante la recidiva tras la dilatación. Las características técnicas de la miotomía extramucosa tipo Heller (intervención funcional, sobre una zona anatómica fácilmente accesible por laparoscopia) ha modificado el abordaje quirúrgico, proponiéndose como una buena indicación para el abordaje laparoscópico. Sin embargo, no existen estudios comparativos sobre la eficacia entre ambos tipos de abordaje. Objetivo. Comparar los resultados inmediatos y a medio plazo tras el tratamiento quirúrgico de la acalasia, bien mediante abordaje abierto o laparoscópico. Material y métodos. Se han revisado los resultados postoperatorios inmediatos y a medio plazo de una serie de 31 pacientes intervenidos entre 1999 y 2000 con el diagnóstico clínico, endoscópico y manométrico de acalasia. Se evaluó la sintomatología pre y poscirugía mediante una puntuación (DeMeester modificado: disfagia, pirosis, dolor y regurgitación [puntuación 0-3]), así como la tasa de conversión, la morbimortalidad inmediata y a medio plazo, la estancia y el grado de satisfacción de la intervención (puntuación 0-4).Resultados. Trece pacientes fueron intervenidos de forma abierta (grupo I) y 18 por laparoscopia (grupo II). En todos ellos se efectúo una miotomía tipo Heller, asociado a una hemiplicatura anterior tipo Dor en 29 o posterior tipo Toupet en 2. Un paciente se convirtió a cirugía abierta y en otro fue imposible crear el neumoperitoneo por adherencias por cirugía previa. Un paciente intervenido previamente por vía abierta fue reoperado por laparoscopia por recidiva de la acalasia.No existieron diferencias en la duración de la intervención (132 ñ 29 frente a 140 ñ 25 min; p: NS) ni en la morbilidad, aunque se observó una significativa reducción de la estancia postoperatoria (7,7 ñ 2 frente a 3,7 ñ 1 días; p < 0,0001) y de la reanudación de la actividad normal (45 ñ 20 frente a 20 ñ 13 días; p < 0,002). Ambas técnicas fueron efectivas de forma similar en la reducción de la sintomatología de la acalasia, aunque el abordaje laparoscópico se acompañó de una mayor satisfacción estética (2,2 ñ 1,1 frente a 3,4 ñ 0,7; < 0,005).Conclusión. El abordaje laparoscópico mantiene las características del tratamiento quirúrgico convencional añadiendo las ventajas de una técnica menos agresiva (AU)