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by Gil Lederman, M.D.
There are multiple fertile areas of investigation in the diagnosis and
treatment of esophageal carcinoma. The esophagus leads between the mouth and
stomach and is responsible for carrying food and liquid through the thorax on
its way to digestion. Cancers that commence in this area are usually announced
by difficulty or pain in swallowing. Sometimes bleeding can be the presenting
symptom and on other occasions, metastatic cancers can be the presenting
manifestation of this disease.
When metastatic esophageal cancer occurs, standard therapy in this country is
systemic chemotherapy although radiation may be used for local symptoms.
Many patients, however, are diagnosed when the cancer appears confined to the
organ of origin - the esophagus.
While surgery may seem desirable, in fact the majority of patients either
have disease spread beyond the esophagus or are not surgical candidates. Even in
those patients who are surgical candidates, the majority are not successfully
treated using invasive surgical approaches. The reason is the high likelihood of
recurrent or metastatic cancer.
Treatment protocols that were developed in the 1980s are maturing. This
information allows evaluation of innovative approaches such as concurrent
systemic chemotherapy and local radiation.
Early studies evaluated the use of this approach and found a number of
patients with complete responses - meaning no evidence of cancer.
Subsequent treatments confirmed the potential efficacy of this approach.
There are two obvious areas of concern in treating a cancer. The first is
control of the local regional area and the second is control of the rest of the
body (systemic). The rationale of systemic chemotherapy is to eradicate not only
the primary but as well any microscopic foci of spread. The role of surgery or
radiation is to control the local site since total body radiation is seldom used
in solid tumors or cancers.
The recent publication from Poplin et al of Wayne State University evaluated
26 patients with esophageal cancer. All but two had squamous carcinoma. The
remaining patients had adenocarcinoma.
Patients were treated using radiation to the esophagus and drugs consisting
of 5-FU and Cis-platin given concurrently with the radiation. Subsequently,
Cis-platin and 5-FU followed radiation. At the conclusion of therapy, patients
were evaluated with endoscopy of the esophagus and CT scans of the body. If the
patients had no obvious residual disease, then three more cycles - or rounds -
of chemotherapy were given. If the patients had cancer, then surgical removal or
additional treatment including radiation and chemotherapy were given. If the
cancer progressed despite this approach, then chemotherapy alone was
offered.
Of the patients treated, ages ranged from 50 to 80 years and most patients
had good performance status or function. It was noted that difficulty swallowing
was either or moderate or severe in most. In fact, 14 of the 26 patients had
feeding tubes placed to help maintain nutrition.
All patients were evaluated and 65% had complete response meaning no evidence
of cancer by endoscopy. The average patient survived 24 months. Patients who did
not respond to treatment had a survival that was markedly shorter. Patients
maintaining their weight or losing small amounts of weight did better than those
with a greater weight loss.
Side effects were numerous. That is not unexpected for patients with a
significant disease undergoing intensive treatment. Of the 26 patients, 19
required hospitalization for inflammation of the esophagus, blood clot or
infection. No deaths were reported due to the cancer treatment.
The authors noted combined modality treatment "demonstrates longer survival
than was demonstrated in other studies using surgery alone or radiation alone.
Most combined modality treatments have in common local radiation, 3000 to 6000
cGy, and chemotherapy consisting of 5-FU and Cis-platin." Surgical removal of
the esophagus was performed only in patients who did not respond to radiation
and chemotherapy rather than being used routinely. Despite this, the authors
noted, "Documented local regional recurrences were surprisingly few in this
study."
New methods of radiation allow high doses of radiation to be placed within
the esophagus minimizing irritation or damage to the surrounding tissue. In
fact, this has been a technique carried out at Staten Island University Hospital
for years. The authors comment on this technique calling it "Brachytherapy
Augmentation." The rationale is enhancing the dose of radiation.
Thus, innovative approaches avoiding the potential morbidity and mortality of esophagectomy (removal of the esophagus) are being developed with data presented to broad medical audiences. The rationale of this approach is obvious - to extend length of life by producing better potentially curative therapies.
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