MANAGEMENT OF OESOPHAGEAL CANCER

Dr.Bogdan Paltineanu
UMF Tg.Mures


Rezumat
Aceas articol este o trecere in revista a datelor din literatura de specialitate privind managementul evaluarii cancerului esofagian si gastric si stadializarea.Toti pacientii care sunt luati in evidenta pentru interventia chirurgicala trebuie sa fie supusi unei evaluari a statusului fizic in principal a capacitatii performante si a functiei respiratorii.Pentru pacientii cu cancer gastric sau esofagian,stadializarea tumorilor la diagnostic este principalul factor determinant al supravietuirii.Implicarea ganglionilor limfatici este cel mai important si singurul factor,urmat de stadiul T.La pacientii cu cancer esofagian ,prezenta nodulilor implicati reduce supravietuirea la 5 ani de la 60-80% la 25%.
Cuvinte cheie:cancer esofagian,stadiu tumoral,ganglioni limfatici

 

Abstract
This article is a review of the literature data on management of oesophageal gastric cancer assesement and staging. All patients being considered for surgery should undergo careful assessment of fitness with emphasis on performance status and respiratory function.For patients with gastric or oesophageal cancer, tumour stage at diagnosis is the main determinant of survival. Lymph node involvement is the most important single factor, followed by T stage.In patients with oesophageal cancer, the presence of involved nodes reduces five year survival from 60-80% to approximately 25%.
Key words:oesophageal cancer,tumor stage,lymph node

 

Introduction
For patients with gastric or oesophageal cancer, tumour stage at diagnosis is the main determinant of survival. Lymph node involvement is the most important single factor, followed by T stage.In patients with oesophageal cancer, the presence of involved nodes reduces five year survival from 60-80% to approximately 25%.
The presence of more than four involved nodes or M1a node involvement is associated with significantly reduced survival, although it does not necessarily preclude long term survival following resection[1]. Long term survival is not seen in patients with junctional cancers who have cervical nodal disease or nodal metastases in three body compartments (neck, mediastinum and abdomen)[2].In patients with gastric cancer both the number of involved nodes and the ratio of involved to uninvolved nodes significantly influence long term outcome.[3,4].
T stage is the most significant factor in node negative cases.[5].In patients with oesophageal cancer preoperative identification of lymph node involvement by EUS is associated with a poor prognosis.[6].Selected patients with T4 gastric cancer in the absence of extensive lymph node involvement can have long term survival (five years and over) following surgical resection[7,8].
The patients most likely to benefit from curative treatment are those without distant metastases and with limited lymph node involvement. Long term survival is possible in highly selected patients with more advanced disease but the majority of patients in this category will survive for less than two years following resection.
Oesophageal cancer should undergo careful preoperative staging to enable targeting of potentially curative treatment to those likely to benefit.
B Patients with oesophageal cancer who have distant metastases or patients with oesophageal cancer who have metastatic lymph nodes in three compartments(neck, mediastinum and abdomen) on preoperative staging are not candidates for curative treatment.
C When M1a nodal involvement in oesophageal cancer, or extensive lymphadenopathy in any cancer, is identified on preoperative staging, the anticipated poor prognosis should be carefully considered when discussing treatment options.
Where there is clear evidence of incurable disease following staging, attempts at resection should be avoided.

 

Tumor stage and quality of life
There is no evidence directly addressing the influence of tumour stage on quality of life in patients with oesophageal cancer. Surgery results in a reduction in quality of life which only returns to preoperative levels in patients surviving more than two years. In these patients quality of life improves after three to four months and approaches preoperative levels at around nine months.[9].
D The possibility of reduction in quality of life after surgery should be considered when discussing treatment options, particularly when preoperative staging suggests that surgery would be unlikely to be curative.

 

Assessement of preoperative fitness
Of all patients with oesophageal cancer who are surgically assessed, over half (57%) are rejected for surgery because they are considered insufficiently fit.[10]. In those who have surgery, respiratory (20-41%) and cardiac (11-16%) complications are the major causes of postoperative mortality.[2,10]. Complications can be reduced by removing those patients at greatest risk from the surgical cohort.[11]. This is most frequently achieved by exercising clinical judgement and there is evidence that this is predictive of in-hospital mortality.[10]. The more objective POSSUM (physiological and operative severity score for the enumeration of mortality and morbidity) scoring system is also predictive of in-hospital death. Both POSSUM and ASA grade(American Society of Anesthesiologists) independently predicted medical complications.[10].
Scoring systems for risk prediction specifically for patients with oesophageal cancer have been developed. Use of a composite scoring system based on general performance status as well as cardiac, hepatic and respiratory function has been shown to reduce postoperative mortality from 9.4% to 1.6% but the system relied on subjective judgement and appeared cumbersome.[11].
A simpler but unvalidated scoring system based on age, spirometry and performance status predicted an incrementally increasing risk of respiratory and cardiac complications although it did not predict postoperative mortality.[12].
A Japanese study found no association between preoperative cardiac or hepatic dysfunction and the development of postoperative complications, but respiratory dysfunction, FVC (forced vital capacity) <80% or FEV1 (forced expiratory volume in first one second)<70%, did predict complications.[13].156 Another Japanese study did not find routine pulmonary function tests useful but found that expired gas analysis during exercise predicted cardiopulmonary complications.[14]. This measure of cardiopulmonary reserve is not routinely available. In an American study of high-risk surgical patients, symptom-limited stair climbing predicted postoperative complications.[15].
The role of dynamic testing of cardiac function has not been addressed in patients with oesophageal cancers.
B All patients being considered for surgery should undergo careful assessment of fitness
with emphasis on performance status and respiratory function.
5.4 pathological Staging of resected specimens SAGOC illustrated the variability in the reporting of the pathology of resection specimens from patients with oesophageal and gastric carcinomas[2].
Accurate completion of pathology reports is essential to ensure accurate pathological staging (for comparison with clinical staging), to inform assessment of prognosis, to indicate the completeness and adequacy of resection and to assist in audit.

 

Important pathological parameters
Resection specimens need to be dissected carefully for accurate tumour staging. Tumour stage correlates with prognosis . The Royal College of Pathologists (RCP), in its standards and minimum data sets has identified important parameters.[16].The RCP standards also give information on the ideal preparation and dissection methods for resection specimens and the information which should be recorded for each resection.
The following parameters have been identified as important in the RCP standards:
Oesophageal, and junctional type I and II cancers – extent within the wall, longitudinal margins, vascular invasion and total number of lymph nodes and number and sites in which there is metastatic tumour. The latter is important to identify M1 nodes as these are associated with a poor prognosis.[2,3,16].

Resection specimens of oesophageal and gastric cancer resections should be reported according to, or supplemented by, the Royal College of Pathologists’ minimum data sets.

 

Assessement and staging
Management of oesophageal and gastric cancer
Treatment principles
The choice of treatment for patients with oesophageal or gastric cancer depends on the stage of the disease, and on the condition and wishes of the patient. Patients with resectable lesions may be unfit for surgery or potentially curative chemoradiotherapy by virtue of significant comorbid disease . The patient’s preoperative status and comorbidity are strong predictors of outcome. The management of all patients should be discussed in an appropriate multidisciplinary meeting (MDM) where all staging and other relevant information is available to all members of the team. Patients should be informed of the treatment options available (surgery, chemotherapy or radiotherapy), and these should be evaluated in terms of risks and benefits.[9].
The management of all patients who are diagnosed with gastric or oesophageal cancer, should be discussed within a multidisciplinary forum.
Stress associated with the diagnosis and treatment of cancer can cause significant psychological morbidity. There is some evidence that providing emotional, spiritual and practical support may have a positive effect on patients’ well-being.[17]. Giving better information and taking time to explain and understand patients’ concerns can result in decreased psychological distress for patients and have a positive impact on patients’ quality of life.[18].
Obtaining support from national and local support groups can improve a patient’s ability to cope and information relating to these support services should be made readily available.[19].

 

Conclusion
Health professionals providing care and treatment for patients with oesophageal or gastric cancer should seek appropriate training in communication skills.
D Information relating to local and national support services should be made available to both patients and carers.
Patients should be given clear information relating to the potential risks and benefits of treatment.

 

References
1. Tachibana M, Dhar DK, Kinugasa S, Kotoh T, Shibakita M, Ohno S, et al. Esophageal cancer with distant lymph node metastasis: prognostic significance of metastatic lymph node ratio. J Clin Gastroenterol 2000;31(4):318-22
2. Lerut T, Nafteux P, Moons J, Coosemans W, Decker G, De Leyn P, et al. Three-field lymphadenectomy for carcinoma of the esophagus and gastroesophageal junction in 174 R0 resections: impact on staging, disease-free survival, and outcome: a plea for adaptation of TNM classification in upper-half esophageal carcinoma. Ann Surg 2004;240(6):962-72.
3. Kim JY, Bae HS. A controlled clinical study of serosa-invasive gastric carcinoma patients who underwent surgery plus intraperitoneal hyperthermo-chemo-perfusion (IHCP). Gastric Cancer 2001;4(1):27-33.
4. Y u CC, D. A. Levison, et al. Pathological prognostic factors in the second British Stomach Cancer Group trial of adjuvant therapy in resectable gastric cancer. Br J Cancer 1995;71(5):1106-10.
5. Kooby DA, Suriawinata A, Klimstra DS, Brennan MF, Karpeh MS. Biologic predictors of survival in node-negative gastric cancer. Ann Surg 2003;237(6):828-35; discussion 35-7.
6. Pfau PR, Ginsberg GG, Lew RJ, Brensinger CM, Kochman ML. EUS predictors of long-term survival in esophageal carcinoma. Gastrointest Endosc 2001;53(4):463-9.
7. Dhar DK, Kubota H, Tachibana M, Kinugasa S, Masunaga R, Shibakita M, et al. Prognosis of T4 gastric carcinoma patients: an appraisal of aggressive surgical treatment. J Surg Oncol 2001;76(4):278-82.
8. 0 Saito H, Tsujitani S, Maeda Y, Fukuda K, Yamaguchi K, Ikeguchi M, et al.Combined resection of invaded organs in patients with T4 gastric carcinoma. Gastric Cancer 2001;4(4):206-11.
9. Blazeby JM, Farndon JR, Donovan J, Alderson D. A prospective longitudinal study examining the quality of life of patients with esophageal carcinoma. Cancer 2000;88(8):1781-7.
10. McCulloch P, Ward J, Tekkis PP. Mortality and morbidity in gastrooesophageal cancer surgery: Initial results of ASCOT multicentre prospective cohort study. BMJ 2003;327(7425):1192-6.
11. Bartels H, Stein HJ, Siewert JR. Preo153 McCulloch P, Ward J, Tekkis PP. Mortality and morbidity in gastrooesophageal cancer surgery: Initial results of ASCOT multicentre
prospective cohort study. BMJ 2003;327(7425):1192-6.
12. Ferguson MK, Durkin AE. Preoperative prediction of the risk of pulmonary complications after esophagectomy for cancer. J Thorac Cardiovasc Surg 2002;123(4):661-9.
13. Nagamatsu Y, Shima I, Yamana H, Fujita H, Shirouzu K, Ishitake T. Preoperative evaluation of cardiopulmonary reserve with the use of expired gas analysis during exercise testing in patients with squamous cell carcinoma of the thoracic esophagus. J Thorac Cardiovasc Surg 2001;121(6):1064-8.
14. Girish M, Trayner E, Jr., Dammann O, Pinto-Plata V, Celli B. Symptomlimited stair climbing as a predictor of postoperative cardiopulmonary complications after high-risk surgery. Chest 2001;120(4):1147-51.
15. Gauss A, Rohm HJ, Schauffelen A, Vogel T, Mohl U, Straehle A, et al. Electrocardiographic exercise stress testing for cardiac risk assessment in patients undergoing noncardiac surgery. Anesthesiology 2001;94(1):38-46.
16. The Royal College of Pathologists. Standards and datasets for reporting cancers.[cited 06 April 2006]. Available from url: http://www.rcpath. org/index.asp?PageID=254
17. Fallowfield L, Ratcliffe D, Jenkins V, Saul J. Psychiatric morbidity and its recognition by doctors in patients with cancer. Br J Cancer 2001;84(8):1011-5.
18. Patient-centred care. In: Department of Health. Guidance on Commissioning Cancer Services: Improving Outcomes in Upper Gastro-intestinal Cancers: The Manual. London: Department of Health;2001. [cited 06 January 2006]. Available from url : http://www.dh.gov.uk/assetRoot/04/08/02/78/04080278.pdf
19. Jenkins V, Fallowfield L, Saul J. Information needs of patients with cancer: results from a large study in UK cancer centres. Br J Cancer 2001;84(1):48-51

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