Preoperative x-ray therapy in cancer of the esophagus.

Abstract

In the coastal area of South Carolina, carcinoma of the esophagus has an unusually high incidence. Studies have revealed no cause for this endemic occurrence. Because of their frequent encounters with the lesion, the authors have had an opportunity to evaluate several approaches to the problem during the past years. There have been, in general, three phases of treatment at the Medical College Hospital (Charleston, S. C.) since 1940. The first covers the period 1940 to 1951; the second, 1951 to 1957; the final phase, 1957 to 1963. The purpose of this report is to compare the results of the different phases and to propose a method of combined radiation and surgery in carcinoma of the esophagus. In addition, the effects of preoperative x-ray therapy on the subsequent operations are evaluated. Changing approaches to the problem have been necessitated by the unsatisfactory results with past technics (1, 2). The relatively favorable cases have included lower-third lesions, many of which are probably of gastric origin (3). Material From 1940 to 1963, 494 patients with carcinoma of the esophagus were observed at this hospital complex. The first group of 170 patients from 1940 to 1951 were treated by surgery alone. The operable rate was 56 patients of 170, or 33 per cent. At operation, 30 of the 56, or 54 per cent, were resectable. The mortality rate was high, however, being 57 per cent (17 of 30). In addition, although 30 cases were resectable, only 6 were thought to be curable at operation (4). Our second group numbered 166 patients. Emphasis during this period (1951–1957) was placed upon x-ray therapy alone, although in some cases x-ray therapy was given subsequent to surgery. Operation was the only treatment in a few instances. The response to irradiation was initially good, with symptomatic and radiographic improvement. Long-term results were poor, as has been the experience elsewhere (2). We had only 2 long-term survivors who received irradiation alone, and both died five years after treatment. Of the patients treated by x-ray therapy alone, 17 were theoretically curable; death resulted from recurrent tumor in 14 of these 17. Two patients treated during the latter part of this phase were given preoperative therapy. One lived six years and the other is alive and well at ten years. In patients treated with surgery only results were similar to those in the first group (1940–1951). The overall two-year survival in the second phase was 5 per cent. The excellent initial response to x-ray therapy stimulated our interest in the possibility of a combined approach. Because of two cases of transverse myelitis, one nine months after supervoltage therapy with 5,000 R tumor dose in three weeks and another ten months subsequent to 6,600 R in seven weeks, we use a tumor dose below 5,000 R.