Prognostic factors influencing survival in combined radiotherapy and surgery of squamous cell carcinoma of the esophagus with special reference to a histopathologic grading system.

Sixty-six patients with squamous cell carcinoma of the esophagus were treated with combined surgery and radiotherapy, mostly in a sandwich fashion. Fourteen patients received misonidazole during preoperative radiotherapy. Prospective cumulative survival at 1, 2, and 5 years was 60%, 35%, and 17%, respectively. Original biopsy specimens and operation specimens were evaluated according to a histopathologic grading system based on an evaluation of the tumor cell population in terms of cell differentiation, structure, nuclear polymorphism, and the frequency of mitotic figures. The tumor-host relationship was also estimated by the mode of invasion, stage of invasion, vascular invasion, and degree of lymphocytic infiltration. A multivariate regression analysis according to Cox and actuarial survival were used to determine the relative contributions of the clinical and histopathologic parameters to patient outcome. The major results were as follows: (1) patients who were old (70 to 80 years) fared as well as younger patients (P = 0.9198); (2) tumor site did not influence therapeutic outcome (P = 0.1100); (3) there was an insignificant difference in survival between patients with M0 and M1 disease (P = 0.7130); (4) radical surgery gave better survival; (5) misonidazole administered preoperatively was associated with worse survival (P = 0.0147); and (6) the histopathologic malignancy grading score system was very useful for prognostication--the tumor-host score in the operative specimen was the strongest of all analyzed predictive parameters. Since palliation was excellent in all patients treated in the combined fashion, selection criteria should be wide for such a program, not the least since long-term survival is possible also for patients with very advanced tumors.

Oesophagectomy without thoracotomy. Experiences from 30 cases.

In 26 patients with malignancies of the oesophagus or cardia and three with benign lesions the intrathoracic oesophagus was resected via abdominal and cervical incisions only and reconstructed with the stomach, a colon interposition or jejunal loop. The operation was chosen to omit the thoracotomy in patients with reduced tolerance to surgery or to secure a safe resectional margin in patients with easily resected tumours. With the exception of two patients, the method was not used for removal of mid-oesophageal tumours. Awareness of the possibility of intrathoracic complications such as bleeding into the pleural cavity is required during the procedure. A high mortality among the older patients contributed to a total mortality of 24%, indicating that the avoidance of a thoracotomy does not necessarily make the operation better tolerated, but it takes less time and postoperative morbidity is reduced.

Pharyngeal dysfunction after total and subtotal oesophagectomy.

Pharyngeal function was studied using a cineradiographic technique in 9 patients following removal of the oesophagus with anastomosis of a substitute in the neck. Pharyngeal dysfunction was present and aspiration occurred in 8 of them. This possible complication should be considered when oesophageal reconstruction with cervical anastomosis is planned. Pharyngeal function should be examined before free eating is allowed.

CT staging of oesophageal carcinoma.

It has been generally accepted that the normal oesophagus, usually in its entire length, is surrounded by fat which facilitates assessment of tumour extension at CT examination in patients with carcinoma. As this contradicts the clinical experience at the hospital, 25 normal subjects and 36 patients with carcinoma of the oesophagus were investigated with computed tomography. In the middle part, where most tumours arise, the oesophagus as a rule was poorly delineated against important structures such as the left main bronchus and the pericardium (left atrium). In the upper and lower oesophagus the delineation was usually better, but none of the normal subjects had a good or at least discernible fat plane in every slice. The typical tumour appeared as a concentric thickening of the wall with broad contact surfaces without interposed fat with adjacent structures such as the trachea, left main bronchus, left atrium, aorta or vertebrae. Most patients received 24 Gy MV treatment followed by surgery and then 40 Gy of radiation. Ten tumours with broad contact surfaces were easily excised while of the five lesions which were relatively well demarcated two needed sharp dissection. These facts make it very difficult to anticipate the surgical findings at CT. The only reliable sign of inoperability was big bulky tumours encroaching on neighbouring organs.

Surgery alone or combined with radiation therapy in esophageal carcinoma.

Two patient-materials with esophageal carcinoma are analyzed: a group of 22 patients who, during the period 1971-1974, were treated with esophageal resection followed by esophagogastrostomy or colonic interpolation; a second group of 28 patients from 1975-1978, who were treated in the same way, but also given either preoperative or postoperative radiation therapy, or both. Surgical mortality was about the same in the two groups: 25-32%. The group given radiation therapy had a one-year survival rate of 50%, as compared with 23% in the group treated solely with surgery. All 24 patients given combined therapy, with all or part of the absorbed dose of 24-47 Gy given preoperatively, showed vital cancer in resected specimens. Vital cancer was found in the periesophageal nodes in only six patients (25%), however; patients given no preoperative radiation therapy had tumor in 20 of 26 cases (77%; P less than 0.01). Celiac nodes were resected at laparotomy; when malignancy was found, the celiac region was irradiated postoperatively. This finding does not appear to exclude long-term survival, as two patients with metastases to the celiac nodes at operation are alive 16 and 20.5 months following surgery. Simple compared to troublesome dissection gives a better rate of survival. The spleen was unintentionally injured in 21 patients at laparotomy and had to be removed. One-year survival was better in patients with intact spleen, especially in those who also had radiation therapy. Patients with resected spleen succumbed from metastases more often than from mediastinal recurrence, as compared with the patients with intact spleen.

[Instrumental perforation of the intrathoracic oesophagus (author's transl)]. / Instrumentelle Perforation des intrathorakalen Osophagus. Erfolgreiche Behandlung einer 90jährigen Frau.

Due to a wide iatrogenic perforation of the oesophagus situated at the level of the carina a 90-year-old woman was admitted to hospital. Prompt recognition and immediate surgery were successful. The operation consisted of a right-sided thoracotomy, wide mediastinotomy, over-sewing of the perforation and pleural drainage. Oesophagostomy and gastrostomy were performed to relieve the oesophagus. A tube was inserted into the duodenum for artificial feeding. This method has been successful in previous cases.

A safe method for pyloromyotomy.

Pyloromyotomy often ends up as a pyloroplasty because of accidental lesions on the duodenal mucosa. This can be avoided. If the incision in the serosa is Y-shaped, the fold of mucosa that partly covers the pyloric muscle can be pushed distally and escape being punctured.