RESUMEN
BACKGROUND: Endoscopic resection (ER) is an important advance in the management of esophageal tumors. It has been used successfully for superficial esophageal cancer and high-grade dysplasia (HGD) arising out of Barrett epithelium. METHODS: From a single institution within the Department of Surgery, patients who underwent ER for esophageal tumors between December 2001 and January 2012 were evaluated. Demographic, clinical, and pathologic variables were collected and reviewed. RESULTS: We identified 81 patients who underwent ER for esophageal lesions. Median patient age was 69 years, and the median follow-up was 3.25 years. In patients with HGD, at the time of last endoscopy, the complete eradication rate of HGD was 84 % and cancer-specific survival was 100 %. During surveillance, one patient developed an invasive carcinoma that required endoscopic therapy. Patients with T1a and negative deep margins on ER had a recurrence-free and cancer-specific survival of 100 %. There were seven patients with T1b and negative margins on ER. Three patients underwent esophagectomy; final pathology revealed no residual malignancy or lymph node metastasis. Two patients had definitive chemoradiation, and two patients were observed. To date, there has been no cancer recurrence. In all patients who underwent ER, there was one episode of bleeding that required endoscopic treatment and admission for observation. CONCLUSIONS: ER can be performed safely and can adequately stage and often treat patients with HGD and superficial cancers. Patients with HGD and T1a disease with negative margins are cured with ER alone. Observation and surveillance may be an option for select patients with low-risk, early submucosal disease (T1b) and negative margins.
Asunto(s)
Esófago de Barrett/cirugía , Endoscopía Gastrointestinal/métodos , Neoplasias Esofágicas/cirugía , Esofagectomía/métodos , Medición de Riesgo/métodos , Adulto , Anciano , Anciano de 80 o más Años , Esófago de Barrett/diagnóstico , Supervivencia sin Enfermedad , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/secundario , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Metástasis Linfática , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/epidemiología , Estadificación de Neoplasias , New York/epidemiología , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Aire , Carcinoma de Pulmón de Células no Pequeñas/psicología , Carcinoma de Pulmón de Células no Pequeñas/cirugía , Miedo , Conocimientos, Actitudes y Práctica en Salud , Neoplasias Pulmonares/psicología , Neoplasias Pulmonares/cirugía , Neumonectomía/psicología , Biopsia/psicología , Características Culturales , Humanos , Metástasis de la Neoplasia , Recurrencia Local de Neoplasia/etiología , Recurrencia Local de Neoplasia/psicología , Siembra Neoplásica , Estadificación de NeoplasiasRESUMEN
PURPOSE: To determine the maximal tolerated dose of capecitabine with oxaliplatin + radiotherapy in a phase I study of localized esophageal cancer. PATIENTS AND METHODS: Oxaliplatin (85 mg/m(2)) administered on days 1, 15, and 29. Capecitabine administered twice daily 5 days weekly; dose levels (DL) were 1, 1000; 2, 1250; and 3, 1500 mg/m(2) with 50.4 Gy radiation. RESULTS: Dose-limiting toxicity was reached at DL 3. Carboxylesterase expression in day 2 tumor specimens and induction correlated with response (p Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico
, Neoplasias Esofágicas/terapia
, Adulto
, Anciano
, Capecitabina
, Carboxilesterasa/genética
, Terapia Combinada
, Citidina Desaminasa/genética
, Desoxicitidina/administración & dosificación
, Desoxicitidina/efectos adversos
, Desoxicitidina/análogos & derivados
, Desoxicitidina/farmacocinética
, Neoplasias Esofágicas/metabolismo
, Femenino
, Fluorouracilo/administración & dosificación
, Fluorouracilo/efectos adversos
, Fluorouracilo/análogos & derivados
, Fluorouracilo/farmacocinética
, Humanos
, Masculino
, Persona de Mediana Edad
, Compuestos Organoplatinos/administración & dosificación
, Compuestos Organoplatinos/efectos adversos
, Compuestos Organoplatinos/farmacocinética
, Oxaliplatino
, Timidina Fosforilasa/genética
RESUMEN
PURPOSE: The combination of oxaliplatin, 5-fluorouracil, and leucovorin with concurrent radiotherapy was demonstrated to be a safe regimen for locally advanced esophageal carcinoma in a prior phase I study. We now report the efficacy data for 42 patients treated with this regimen. METHODS: Each chemotherapy cycle lasted 29 days and consisted of 5-fluorouracil, 180 mg/m2 protracted-infusion from days 1 to 29, and oxaliplatin, 85 mg/m2 on days 1, 15, and 29. The first cycle was administered concurrently with radiation. The radiation field included regional lymph nodes as well as the primary tumor or tumor bed to a dose of 50.4 Gy in 28 fractions. After concurrent chemoradiotherapy, 1 to 2 additional cycles of chemotherapy were administered. If esophagectomy was indicated, it occurred 4 weeks after completion of concurrent chemoradiotherapy. In the adjuvant group, concurrent chemoradiotherapy was initiated 4 weeks after surgery. RESULTS: Median age was 61 years (range 38-78 years); 30 (71%) of the patients were male. Thirty-three patients had adenocarcinoma, and 9 had squamous cell carcinoma. Concurrent chemoradiotherapy was administered preoperatively (group 1) in 24 patients, definitively (group 2) in 13 patients, and as adjuvant treatment (group 3) in 5 patients. In group 1, 16 patients were down-staged including 1 patient with minimal residual disease and 5 with a complete pathologic response; 4 patients were not down-staged, and 4 did not undergo esophagectomy (2 progressed, 1 died of unrelated causes, and 1 refused). In group 2, 1 patient had a complete clinical response, 4 others were down-staged, 2 had stable disease, and 6 progressed. Four patients in group 3 progressed. Median survival was 28 months for group 1, 12 months for group 2, and not reached at 14 months for group 3. There was one grade 4 toxicity (anaphylaxis) in group 2. Grade 3 toxicities were reported for 5 patients in group 1 and 1 patient in group 2. They consisted of hypotension (n=1), fatigue (n=2), diarrhea (n=2), neuropathy (n=1), mucositis (n=1), pneumonitis (n=1), dehydration (n=1), emesis (n=1), and weight loss (n=1). CONCLUSIONS: Our study supports the incorporation of oxaliplatin into a multimodal concurrent chemoradiotherapy protocol for locally advanced esophageal cancer.
Asunto(s)
Adenocarcinoma/terapia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carcinoma de Células Escamosas/terapia , Neoplasias Esofágicas/terapia , Adenocarcinoma/mortalidad , Adenocarcinoma/patología , Adulto , Anciano , Carcinoma de Células Escamosas/mortalidad , Carcinoma de Células Escamosas/patología , Fraccionamiento de la Dosis de Radiación , Neoplasias Esofágicas/mortalidad , Neoplasias Esofágicas/patología , Esofagectomía , Femenino , Fluorouracilo/administración & dosificación , Humanos , Masculino , Persona de Mediana Edad , Compuestos Organoplatinos/administración & dosificación , Oxaliplatino , Radioterapia Adyuvante , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Chylothorax is a rare complication of pulmonary resection. It requires prompt treatment, which is initially conservative. This treatment consists of drainage, nutritional support, and measures to diminish chyle flow. Surgical intervention is indicated when conservative management is ineffective. Delay in surgical intervention leads not only to serious metabolic, nutritional, and immunologic disturbances from the loss of chyle but also increases the risk for adhesion formation, loculation, organization, and infection of the chylothorax, making subsequent surgical attempts difficult and increasing postoperative morbidity and mortality. VATS provides a minimally invasive approach for the treatment of chylothorax complicating pulmonary resection. Clipping of the thoracic duct or chemical pleurodesis may be performed with minimal morbidity and mortality. Conservative treatment is expensive and fails in most patients who have high-output chylous fistulae. On the other hand, VATS is uniformly effective, is less expensive, and has low morbidity. Indeed, VATS is rapidly becoming the preferred approach for the management of chylothorax complicating pulmonary resection. The need to prevent the occurrence of a chylothorax by careful dissection techniques and liberal clipping of lymphatic vessels particularly in areas of high anatomic risk during the initial operation cannot be overemphasized.
Asunto(s)
Quilotórax/diagnóstico , Quilotórax/terapia , Quilotórax/etiología , Drenaje , Etilefrina/uso terapéutico , Humanos , Linfografía , Neumonectomía/efectos adversos , Somatostatina/uso terapéutico , Simpatomiméticos/uso terapéutico , Conducto Torácico/anatomía & histología , Conducto Torácico/lesiones , Conducto Torácico/fisiología , ToracotomíaRESUMEN
Technical advances have resulted in the growing popularity and success of video-assisted thoracoscopic lobectomy for the treatment of nonsmall cell lung cancer. Several investigators have used similar techniques to safely perform pneumonectomies. Minimally invasive pneumonectomy may be indicated for patients who have centrally located malignant lesions and who are not candidates for sleeve resections. Adequate exposure of the proximal hilar vessels is mandatory. Short-term results are encouraging, but prospective long-term data are essential.