Advanced esophageal carcinoma

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Abstract
From 1976 until 1990 a total of 212 patients with squamous cell carcinoma of the thoracic esophagus were referred for surgical treatment. Resectability was 84.1% (161 of 191). Actuarial 5‐year survival in patients with negative lymph nodes was 51.2% versus 12.4% in lymph nodepositive 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+org) irrespective of their lymph node status. Comparing complete (R0) versus incomplete (R1–R2) resections for stage III and IV carcinoma revealed 20% and 0% five‐year survivals, respectively. There was no 5‐year survival in the stage IV group. When excluding solid organ metastasis, the median survival shifted from 8.5 months after incomplete (R1–R2) to 20 months after complete (R0) resection. In 1991 three‐field lymphadenectomy was initiated that included bilateral cervical lymphadenectomy. Thirty‐seven patients have been treated so far (23 squamous cell carcinoma, 14 adenocarcinomas). Cervical lymph nodes were positive in 24.3% with an incidence up to 28.5% for distal‐third carcinoma. Subsequently, 6 patients (16%) moved from M0 to M+Ly status. Our results confirm the key role of surgery not only in improving survival and locoregional tumor control but in refining the accuracy of staging advanced carcinomas provided complete resection is possible. Nowadays other options in the treatment of advanced carcinoma are mainly based on neoadjuvant chemoradiotherapy with response rates ranging from 40% to 60% but until now without evidence of improved 5‐year survival rates and with local or distant failure rates of approximately 30% and 45%, respectively. For clinically nonresectable (T4) or presumed nonresectable tumors, neoadjuvant therapy seems to have an important role, as it may convert these tumors into resectable and therefore potentially curable cancers. Toxicity remains a drawback, as it is probably responsible for preoperative dropouts and slight but definitive higher postoperative mortality and morbidity. When the disease clearly is incurable, the best options today are laser therapy and an endoprosthesis, which result in good relief of dysphagia in approximately 80% to 85% of patients and a procedure‐related mortality below 5%.