Squamous cell carcinoma and adenocarcinoma of the lower third of the esophagus and gastric cardia: similarities and differences.

Squamous cell carcinoma (SCC) and adenocarcinoma (ADC) of the lower esophagus and gastric cardia were compared in their clinical features and long-term prognosis. Two hundred and ninety-five patients with SCC and 263 with ADC were reviewed. Resectability rates for SCC and ADC were 74.2% and 73.2% respectively (P=0.8). Among those who underwent resection, ADC was more advanced, with 22.3% at stage IV compared with 7.4% for SCC (P=0.001). Postoperative cardiac events occurred in 24.2% of SCC patients and 14.7% of ADC patients (P=0.015), and major respiratory complications in 20.1% and 8.6% respectively (P=0.001). Thirty-day mortality rates were 2.7% and 4% (P=0.46), and hospital mortality rates were 11.4% and 7.6% (P=0.19). Median survival rates were 12.5 months for SCC and 11.6 months for ADC (P=0.99) and 5-year survival rates were 19.9% and 17.6% (P=0.55) respectively. Squamous cell carcinoma of the lower esophagus and ADC of the cardia differed in patient demographics and clinical features but long-term prognoses were similar.

Critical appraisal of the significance of intrathoracic anastomotic leakage after esophagectomy for cancer.

BACKGROUND: Leakage from esophageal anastomoses is higher than that for other gastrointestinal anastomoses. An intrathoracic anastomotic leak is a potentially catastrophic event. METHODS: Patients with and without thoracic anastomotic leakage were compared for predisposing factors. Leak-related mortality was analyzed. RESULTS: Of 475 patients, there were 17 leaks (3.5%). Predisposing technical factors occurred significantly more frequently in patients who leaked. Sixteen such events were identified as contributory in 11 patients. The hospital mortality for patients who leaked was significantly higher (35% versus 9%, P = 0.005). Inadequate drainage and persistent sepsis accounted for 4 of the 6 deaths. The need for inotropic support postoperatively correlated with leak-related mortality (66% versus 0%, P = 0.006), while leak size, time to diagnosis, or method of drainage did not. CONCLUSIONS: Thoracic anastomotic leaks are largely preventable. Leak-related mortality for the series was 1% and was most commonly related to inadequate drainage.

Analysis of reduced death and complication rates after esophageal resection.

OBJECTIVE: To identify factors that have contributed to reduced rates of death and complications after esophageal resection in a 17-year period at a tertiary referral center. SUMMARY BACKGROUND DATA: There has been an evolving refinement in surgical technique and perioperative management of patients undergoing esophageal resection at Queen Mary Hospital during the past two decades. As of the end of 1998, there had been no hospital deaths among the last 105 consecutive resections performed for esophageal squamous cancer. METHODS: The results of esophageal resection for squamous cell carcinoma were analyzed using a prospective esophageal database. A longitudinal study was performed to compare and analyze rates of death and complications for three consecutive time periods. RESULTS: The study group comprised 710 patients who underwent one-stage esophageal resection between 1982 and 1998. A transthoracic esophagectomy was the preferred approach in 590 patients (83%). The overall hospital death rate was 11%. The leading causes of hospital death were pulmonary complications (45.5%) and progression of malignant disease (21.5%); anastomotic leakage accounted for 9% of deaths. During the study period, the hospital death rate decreased from 16% to 3.2%, and the incidence of postoperative respiratory failure decreased from 15.5% to 6.5%. Perioperative factors that correlated with the decreased death rate over time were the increased postoperative use of epidural analgesia and bronchoscopy (for clearance of pulmonary secretions), a decrease in history of smoking, and a decrease in surgical blood loss of more than 1,000 mL. CONCLUSIONS: In this series of predominantly transthoracic esophagectomies, there has been a decline in the hospital death rate to less than 5%. These results are largely attributable to factors aimed at reducing postoperative pulmonary complications.

A 25-year thymoma treatment review.

Most thymomas are stage I or II at presentation, and they have a good prognosis with surgical treatment. Higher stage thymomas are less common and their treatment is more problematic. Our center tends to attract patients with higher stage thymomas for treatment. We reviewed our experience and contrasted it with other published series. A 25-year retrospective record review of thymomas was done. 38 patients were treated. Median age was 49 years. Four had myasthenia gravis. Masaoka staging was: stage I--9; stage II--6; stage III--15; stage IVa--4; stage IVb--4. Resection was done in 25 patients (21 had R0 resection), chemotherapy was given to 15 patients, and 27 patients received radiotherapy. Overall median survival was 55 months. Overall 5 and 10-year survivals were 30% and 18%. 5-year survival by stage was: stage I--75%; stage II--50%; stage III/IV--23%. Negative prognostic factors on univariate analysis included presence of symptoms at presentation (p = 0.02), unresectable tumor (p = 0.06), stage III/IV (p = 0.04), and disease recurrence after resection (p = 0.0001). On multivariate analysis, only stage (p = 0.04) and recurrence (p = 0.0001) were independent predictors of survival. All patients who recurred after resection eventually died of disease. Our overall treatment results are disappointing, but we had higher stage patients than reported by most other centers. Early stage thymomas are suitable for complete surgical resection, and the prognosis is favorable. However, higher stage thymomas (stage III and higher) pose problems for complete surgical resection and their prognosis is poor. Newer multimodality treatment approaches are indicated for higher stage thymomas.

Bronchogenic carcinoma in patients age 30 and younger.

BACKGROUND: Lung cancer is rare in patients 30 years of age or younger. There is very little published data on lung cancer in this group of patients. METHODS: A retrospective review of patients 30 years of age and younger with bronchogenic carcinoma treated at Roswell Park Cancer Institute between 1973 and 1994 was done. RESULTS: There were 20 patients (11 female and 9 male). Mean age was 27 years (range, 19-30). The predominant histologic types were adenocarcinoma in 11 patients (55%), and undifferentiated large-cell carcinoma in 5 patients (25%). All patients presented with either stage III (8 patients) or IV disease (12 patients). Eight patients (40%) underwent surgical resection (2 lobectomies, 6 pneumonectomies). Other treatments included chemotherapy in 15 patients (75%) and radiation therapy in 7 (35%). Median survival was only 5.5 months, and there were no 5-year survivors. Univariate analysis identified stage (p = 0.05), resection (p = 0.0005), and treatment with chemotherapy (p = 0.001) as predictors of survival. On multivariate analysis, resection (p = 0.0001) and chemotherapy (p = 0.001) remained as independent predictors of survival. CONCLUSIONS: Young patients with lung cancer present with advanced-stage disease and their cancers appear to be biologically aggressive. Although curative treatment is rarely possible, aggressive multimodality therapy is warranted.

Primary extremity sarcoma: what is the appropriate follow-up?

BACKGROUND: Our objective was to evaluate the effectiveness of follow-up tests for detecting first local and distant recurrences in patients with primary extremity soft tissue sarcoma. METHODS: We retrospectively analyzed all adult cases of primary extremity soft tissue sarcoma (n = 174) treated between 1982 and 1992. Patients were observed every 3 months for 2 years, every 4 months the third year, every 6 months the next 2 years, and annually, thereafter. Each visit consisted of taking the patient's history, a physical examination, a complete blood count, a blood chemistry panel, and a chest x-ray. For high-grade tumors, the primary site was imaged annually when clinically appropriate. RESULTS: Of 141 patients who were assessable, 29 patients developed local recurrence and 57 developed distant recurrence. All but one of the local recurrences was detected on the basis of an abnormal physical examination. Of the 29 patients who developed local recurrence, 25 were resected. Distant metastases were detected because of symptoms in 21 cases. Of the 36 asymptomatic lung recurrences, 30 were detected by follow-up chest x-ray. Of the 36 asymptomatic lung recurrences, 24 patients underwent metastasectomy. The positive and negative predictive values of surveillance chest x-ray were 92% and 97%, respectively. Laboratory testing never led to the detection of recurrence. CONCLUSIONS: Close surveillance by clinical assessment and chest x-ray is appropriate for follow-up observation of patients with primary extremity soft tissue sarcoma.

Effective follow-up strategies in soft tissue sarcoma.

The value of surveillance for detection of recurrences in patients with soft tissue sarcoma (STS) after definitive surgical resection of the primary tumor is based on the premise that early recognition and treatment of local or distant recurrence can prolong survival. Surveillance strategies should meet the criteria of easy implementation, accuracy, and cost-effectiveness. Although guidelines have been proposed for follow-up of patients with STS, there are few data in the medical literature on the effectiveness of these recommendations. We reviewed the effectiveness of a surveillance program for primary extremity STS in an effort to provide an evidence-based rationale for follow-up of STS. We concluded that clinical assessment of patient symptoms, chest X-ray imaging, and physical examination are effective strategies for follow-up of extremity STS. Chest X-ray imaging also appears to be cost-effective, at least for high-grade extremity STS. Imaging of the primary extremity site by computed tomography (CT) scan or magnetic resonance imaging (MRI) on an annual basis and routine laboratory blood tests were ineffective strategies for recurrence detection. However, certain patient characteristics such as body habitus, previous radiation therapy, and location of the primary tumor site may require the use of CT scans and MRI for adequate clinical assessment. The role of specific surveillance strategies for recurrence detection for sarcomas of the trunk, head and neck, retroperitoneum, and viscera has yet to be defined.

Bronchogenic carcinoma in young patients.

BACKGROUND AND OBJECTIVES: Some investigators have suggested that lung cancer in young patients has a more aggressive course and poorer prognosis than lung cancer in older patients. METHODS: A retrospective review is presented of patients less than 40 years of age with bronchogenic carcinoma treated at Roswell Park Cancer Institute between 1984 and 1994, with comparison to a cohort of patients treated in the previous decade. RESULTS: There were 76 patients (41 male and 35 female). Mean age was 35 years (range, 26-39). Adenocarcinoma in 33 patients (43%) and undifferentiated large-cell carcinoma in 22 patients (29%) were the predominant histologic types. Stage IIIa or greater disease was present in 63 (83%) patients. Treatment consisted of chemotherapy (55 patients), radiation therapy (54 patients), and surgery (33 patients). Surgical procedures included pneumonectomy (14 patients), lobectomy (11 patients), wedge resection (1 patient), and thoracotomy only for unresectable disease (7 patients). Operative mortality was 6% (two patients who had radical pneumonectomy for T4 cancer). Median survival for the entire group of patients was 10.4 months, and 5-year survival was 8%. Univariate analysis identified acute presentation (P = 0.02), no resection (P = 0.0001), and higher stage (P = 0.0001) as negative prognostic factors. On multivariate analysis, stage of disease was the only independent predictor of survival (P = 0.005). Resectability was slightly higher (34%, 26/76, vs. 21%, 19/89; P = 0.06) and survival was marginally better (median 10.4 vs. 7.5 months; P = 0.05) than that seen at our institution in the previous decade. CONCLUSIONS: Young patients with lung cancer often have advanced disease at the time of presentation. Nevertheless, they should be treated in accordance with standard stage-specific treatment guidelines.

Delayed cervical esophagogastric anastomosis.

Although uncommon, ischemia of the gastric fundus can lead to catastrophic anastomotic complications after transhiatal esophagectomy. "Delaying" the anastomosis may prevent complications in occasional patients with particularly compromised gastric fundal perfusion.

Primary tumors of the mediastinum.

BACKGROUND AND OBJECTIVES: Diagnostic and therapeutic approaches to mediastinal tumors have changed over the past three decades. We reviewed our recent experience with these tumors and assessed the role of a multidisciplinary treatment approach. METHODS: A retrospective review of 124 patients with primary mediastinal tumors over a 25-year period. RESULTS: Median age was 35 years. Symptoms were present in 86 of 124 (69%) patients. One hundred and eleven of 124 (90%) tumors were malignant. Distant metastases were present at diagnosis in 14 of 124 (11%) patients. The most common tumor was thymoma (38/124, 31%), followed by germ-cell tumor (29/124, 23%), lymphoma (24/124, 19%), and neurogenic tumors (15/124, 12%). Seventy-four of 124 (60%) patients underwent resection, 88 (71%) received chemotherapy, and 97 (78%) received radiation therapy. Tumor recurrence occurred in 52% (47/91) of patients who initially had a complete resection or response to treatment. Median time to recurrence was 10 months. Overall median survival was 44 months. Metastatic disease at presentation (P = 0.02) and tumor recurrence (P = 0.00001) were the only significant independent predictors of survival on multivariate analysis. CONCLUSIONS: Malignant primary mediastinal tumors often require multimodality treatment. Despite improvements in survival with multimodality treatment, death from recurrent disease remains a problem.

Long-term survival after locally aggressive anorectal melanoma.

Anorectal melanoma is a rare disease and, unlike cutaneous melanoma, there are few guidelines regarding optimal management. It has a reputation for having a poor prognosis, which has been attributed to a delay in diagnosis and to a lack of effective systemic therapy. It has also been suggested that the biology of this tumor may differ from that of cutaneous melanoma. An interesting case of anorectal melanoma is presented which highlights the unique considerations and challenges encountered by medical oncologists and surgeons who treat this disease.

Primary gastrointestinal non-Hodgkin's lymphoma: increasingly AIDS-related.

A retrospective study was conducted to determine the influence of the acquired immunodeficiency syndrome (AIDS) epidemic on the incidence, clinical presentation, and outcome of primary gastrointestinal lymphoma (stages I and II) over a 20-year period at a single institution. Between 1971 and 1981, there were seven cases. Fifty-eight patients were diagnosed between 1983 and 1993, and 81 per cent were AIDS-related. The mean age overall was 50 years; 81 per cent were male, and 35 per cent presented with acute complications. All tumors were high or intermediate grade B cell lymphomas, and 48 per cent had bulky or advanced disease at presentation. The overall actuarial 5-year survival was 9 per cent. Human immunodeficiency virus status and stage were significant independent prognostic factors. The AIDS-related subgroup had a mean age of 43 years, and 91 per cent were male. Tumor resection was performed in 38 per cent, and the 5-year survival was 2 per cent. The mean age for the non-AIDS-related subgroup was 71 years, and 55 per cent were male. Resection was performed in 39 per cent, and 5-year survival was 28 per cent. AIDS-related disease accounted for the dramatic increase in incidence of primary gastrointestinal lymphoma since 1983. The prognosis for these patients is poor and is dominated by the underlying immunocompromise.

Carcinoma of the breast during pregnancy: a review and update on treatment options.

Gestational breast cancer is occurring with increasing incidence because more women are delaying childbirth into their thirties and forties. Although breast cancer during pregnancy or within the first year postpartum is occurring more often, there is still some confusion regarding its treatment. Although breast conservation therapy has evolved as the major treatment in breast cancer, it has been thought that pregnancy was a contraindication for this type of breast cancer therapy due to risks imposed on the fetus by chemotherapy and radiation. However, recent studies have shown that the use of chemotherapeutics during the second and third trimesters is possible. Also, if chemotherapy is initiated after a lumpectomy, radiation can be withheld until after the birth of the baby when the cancer is detected in the second or third trimester.

N-cadherin promotes adhesion between invasive breast cancer cells and the stroma.

Calcium-dependent cell adhesion molecules (cadherins) are involved in maintaining the epithelial structure of a number of tissues including the mammary gland. In breast and other tumor types, loss of E-cadherin expression has been seen in high grade tumors and correlates with increased invasiveness. Here we show high levels of expression of N-cadherin in the most invasive breast cancer cell lines which was inversely correlated with their expression of E-cadherin. A stromal cell line also expressed N-cadherin in accordance with its fibroblastic morphology. N-cadherin localized to areas of cell-cell contact in all cells that expressed it. Calcium-dependent intercellular adhesion of N-cadherin-expressing breast cancer and stromal cells was specifically inhibited by an anti N-cadherin monoclonal antibody. In addition, N-cadherin promoted the interaction of invasive breast cancer cells with mammary stromal cells; in contrast, E-cadherin expressing cell lines did not co-aggregate with stromal cells. The combined results suggest a functional role for N-cadherin in cohesion of breast tumor cells which, in addition promotes their interaction with the surrounding stromal cells, thereby facilitating invasion and metastasis.

Surgical management of melanoma.

The incidence of melanoma is rising more rapidly than any other malignancy. More conservative margins of excision have been established and the role of elective node dissection awaits determination by prospective randomized trials. Lymphoscintigraphy has clarified lymphatic drainage from watershed areas. Lymphatic mapping and sentinel node biopsy may lead to acceptance of selective lymphadenectomy, and also allows for more sensitive staging. Further advances in outcome require the development of effective systemic adjuvant therapies. Until such time, surgery continues to play a pivotal role in all stages.