Selective therapeutic approach to cancer of the lower esophagus and cardia.

The role of curative en bloc resection for carcinoma of the lower esophagus and cardia is still controversial. The experience with a selective approach in 52 patients with cancer in this location is reviewed. Thirty-two of the cancers were squamous cell, 13 adenocarcinoma, and seven adenocarcinoma associated with Barrett's esophagus. In 19, the tumor was not resectable and all of these patients died within a year. In 19 patients, a palliative resection could be done. Actuarial survival was 31% at 1 year. Only one patient was alive after 5 years. Initially, 16 patients with noncircumferential lesions on endoscopy and/or no evidence of spread to mediastinal lymph nodes on computed tomographic scan were considered to have potentially curable lesions. All were less than 75 years old and had a forced expiratory volume in 1 second greater than 1.5 L and a resting ejection fraction greater than 40%. A curative resection consisting of an en bloc thoracic esophagectomy, mediastinal lymphadenectomy, and an 80% gastrectomy with abdominal lymphadenectomy was performed in 14. The left colon was used to reestablish the gastrointestinal continuity. Two patients had more extensive disease discovered at operation, and the curative en bloc resection was abandoned. Absence of full wall penetration or involvement of four or fewer regional nodes, or both, was correctly predicted by preoperative and intraoperative staging in 86% of the patients. Operative mortality of a curative en bloc resection was 7% (1/14), and the actuarial survival rates were 76%, 66%, and 53% at 1, 2, and 5 years. Inferences are made from these results on tumor characteristics associated with survival, the extent of resection necessary for cure, the difficulty of accomplishing a curative en bloc resection by the transhiatal approach, the contraindication to curative en bloc resection, and the need for a surveillance program for patients with Barrett's esophagus.