CARCINOMA OF THE CERVICAL ESOPHAGUS

My experience with cancers of the cervical esophagus has been a most unhappy one. In the first place, it is rare to encounter a tumor in this region which is operable and resectable. The extent of peripheral growth with involvement of neighboring structures would classify any attempt at radical excision as a tour de force. Secondly, the Wookey operation or any modification thereof is a complicated multiple-stage procedure which includes laryngectomy and the use of skin flaps and grafts which are prone to necrosis. Thirdly, and most important, the long-term results leave much to be desired. There are very few reported patients who have survived more than five years. In effect, practically all attempts to excise tumors in this region must be considered as palliative. For these reasons, I gave up operating on cancers of the cervical esophagus some years ago and refer all such cases for radiation therapy. The superficial location of this part of the organ and the known sensitivity of these tumors to the x-ray make irradiation a more desirable method of therapy. It has been my experience that the patients treated by radiation methods live longer than those subjected to operation and without the physical disability and prolonged convalescence which always are part of the surgical approach.

Statistics. The detailed results of our efforts in the surgical therapy of cancer of the esophagus have been published so often that they need not be repeated here. Briefly, the operative mortality has decreased from 32 percent to 10 percent in the last 40 cases. Operability has averaged about 50 percent. The absolute survival rate, which includes the inoperable patients, the operative deaths, and the survivors, is 7 percent. Among the operative survivors the late results are: 18 percent for periods varying between 2 and 21Vi years for cancers of the middle third, and 20 percent between 2 and 17 years for lower third growths. The 21 Vi year survival had a Torek procedure for a mucosal cancer and died at the age of 80 of a cerebral accident following a hip fracture.

Among the cardial carcinomas, operability averaged 48 percent. The absolute survival rate, which includes the inoperable patients, the operative deaths, and the survivors, is 5.5 percent. Among the survivors, 15 percent lived from 3 to 18 years. When the transthoracic approach was used, the operative mortality was 24 percent. With the advent of the abdominothoracic approach, the operative mortality dropped to 6 percent.

*Another feature with respect to preoperative radiation is the frequency of lymph node involvement below the diaphragm. As already mentioned, retrograde metastatic involvement to the nodes along the left gastric vessels occurs in approximately 50 percent of the patients with squamous-cell cancers of the esophagus. Preoperative radiation confined only to the primary growth leaves this high incidence of subdiaphragmatic spread untouched. There appears to be great reluctance to radiate this region and, probably, rightly so. The effect on the stomach or other viscera to be used for transplantation would undoubtedly be considerable. This is part of the problem of preoperative radiation that must be clarified before the final answer is obtained.

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