Environmental factors and high risk of esophageal cancer among men in coastal South Carolina.

A case-control study involving interviews of 207 men with esophageal cancer and 422 control subjects or their next of kin was conducted to identify reasons for the unusually high rates of esophageal cancer among men in coastal South Carolina. Tobacco and alcohol, including moonshine, were identified as the major determinants of esophageal cancer risk. Increased risk was also associated with low intake of fresh fruits but not with drinking of local herbal teas. The findings suggest that efforts aimed at reducing tobacco and alcohol use will help to lower the elevated rates of esophageal cancer in coastal South Carolina.

Palliative radiotherapy for inoperable carcinoma of the lung: final report of a RTOG multi-institutional trial.

Between June 1973 and February 1979, 409 patients with inoperable advanced non-oat cell carcinoma of the lung were randomized on RTOG protocol 73-02. Three treatment arms were evaluated: 40 Gy split course, 30 Gy continuous course, and 40 Gy continuous course. Patients were also randomized to receive cytoxan or no further therapy following irradiation. Three hundred sixteen patients were evaluable. Palliation of symptoms was achieved in 60% with 1/4 of the patients becoming symptom-free. Complete regression of local and regional tumor was produced in 15% and partial regression in 26%. There is no significant difference between the treatment arms in these objective response rates. Median survival times were approximately 6 months. No significant benefit was demonstrated by the adjuvant use of Cytoxan. Although the number of complete responses produced was relatively small, patients achieving a complete response had a significantly longer median survival than the remaining patients, i.e., 14.5 months versus 6 months. Significant toxicity occurred in fewer than 6% of patients. Radiation pneumonitis counted for the majority of these adverse reactions. Toxicity occurred somewhat more often in the group treated with 40 Gy split course therapy. Implications for further studies are discussed.

Split-course versus continuous pelvis irradiation in carcinoma of the uterine cervix: a prospective randomized clinical trial of the Radiation Therapy Oncology Group.

In August 1980, the Radiation Therapy Oncology Group (RTOG) completed a prospective randomized clinical trial for the comparison of a split-course versus a standard continuous course of pelvic irradiation for carcinoma of the uterine cervix Stages II-B, III-A, III-B, and IV-A. The split-course consisted of 10 fractions of 250 rad each, 5 times a week, up to 2500 rad followed by a rest period of approximately 2 weeks and then another 2500 rad was given (250 X 10). The continuous course consisted of 30 fractions of 170 rad each, 5 times per week, for a total of 5100 rad. In both groups the external pelvis irradiation was followed by intracavitary brachytherapy in the uterus and vagina, with tandem-colpostat or tandem only, for a dose of 3000 rad at point A for the former, or at 2 cm from the center of the linear source for the latter. In cases where brachytherapy was not possible, a boost of external irradiation with reduced field, with a dose of 1600 rad (200 X 8) was advised. Three hundred and one patients were registered, of which 287 are currently evaluable. No differences between the treatments were detected for the following study end-points: treatment tolerance in terms of acute normal tissue reactions and completion of therapy, tumor control in the pelvis, severe late normal tissue reactions, and survival. In the entire study population the estimated tumor control in the pelvis at two years after initiation of therapy was: 81% for Stage II-B, 67% for III-A, 53% for Stage III-B, and 32% for Stage IV-A. The estimated two-year survival was: 70% for Stage II-B, 58% for III-A, 46% for III-B, and 23% for IV-A.

Chemotherapy, radiation therapy, and resection for carcinoma of the esophagus. Long-term results.

From May 1980 to May 1984, preoperative chemotherapy (mitomycin C and 5-fluorouracil) was added to radiation therapy in patients with potentially operable squamous cell carcinoma of the esophagus. Of 129 patients observed, 122 were followed up until death or to the present. Only 33 were able to complete preoperative chemotherapy and radiation and undergo resection. There were 28 men and five women, their ages ranging from 42 to 81 years (average 60 years). There were 22 black and 11 white patients. The location of the tumor was in the middle third in 70% of the patients. Among the 33 patients, the clinical TNM classification was as follows: T1 N0 M0, three patients; T2 N0 M0, 27 patients; T2 N1 M0, two patients; and T3 N0 M0, one patient. The length of the lesions when measurable in the absence of complete obstruction varied from 3 to 17 cm (average 7 cm). The operative mortality rate in this group was 12% (4/33). There was no viable residual tumor in the surgical specimen of the esophagus in 33% (11/33) of those patients completing triple therapy. However, in two of the 11 patients, left gastric nodes contained tumor and in one there was a minute esophageal perforation. The 2-year survival rate was 33% (11/33), and the 5-year survival rate was 15.4% (5/33). Among the 11 patients having 2-year survival, the surgical specimen was normal in six and abnormal in five. Of the five patients having 5-year survival, the surgical specimen was normal in three and abnormal in two. The absence of tumor in the surgical specimen did not appear to confer any better chance for long-term survival. Data were compared to our 1967-1975 series of 75 patients receiving only preoperative radiation and resection. There was no significant difference in survival rates at 2 years (20% [1975] versus 33% [1984], p = 0.2118) or at 5 years (10% [1975] versus 15.4% [1984], p = 0.5796). The addition of preoperative chemotherapy as an adjunct did not result in a statistically significant increase in 2-year or 5-year survival rates.

Chemoradiation therapy and resection for carcinoma of the esophagus: short-term results.

The purpose of this report is to record the results of a treatment protocol for patients with carcinoma of the esophagus. In May, 1980, we initiated a program of chemoradiation therapy preliminary to resection in patients in whom the protocol was applicable. The chemotherapy consisted of mitomycin-C, 10 mg as a bolus intravenous injection on day 1, and 5-fluorouracil, 1,000 mg per square meter of body surface area in 1,000 ml of 5% glucose solution in distilled water given intravenously on each of days 1 through 4. The radiation therapy consisted of 3,000 rads in three weeks using cobalt 60 or 6 MeV or greater, with ports to cover the tumor and mediastinum. This protocol was given to patients with primary carcinoma of the esophagus whose disease remained or became operable during or following the course of the chemoradiation. Among the patients treated according to the protocol, the operability rate was increased. The resectability rate remained about the same as in our previous experience. The operative mortality was lessened appreciably. The percentage of resected specimens of the esophagus showing residual tumor decreased. However, the absence of any residual tumor in the surgical specimen has not conferred any improved chance of long-term survival to date. There has been a two-year survival of 33% (7/21) among the small group having chemoradiation therapy prior to resection, and this figure is roughly the same as that in our previously reported series of patients treated by preoperative irradiation (4,500 rads in three weeks) and resection without the chemotherapeutic adjunct.(ABSTRACT TRUNCATED AT 250 WORDS)

Peptic strictures of the esophagus.

Peptic esophageal strictures are a common sequelae of long-standing reflux esophagitis. Factors predisposing to stricture formation are poorly understood; however, stricture patients are typically older, have a longer duration of reflux symptoms, have significantly lower lower esophageal sphincter pressures, and more frequently display abnormal esophageal motility than reflux patients without strictures. A careful history should suggest the diagnosis in most cases, but should be confirmed with a barium esophagram followed by endoscopy with biopsies to exclude malignancy. The therapeutic armamentarium for treating peptic strictures has greatly expanded during the past 30 yr. It now includes potent anti-secretory medications, bougienage with flexible polyethylene dilators or balloons, and anti-reflux surgery. Aggressive medical therapy combined with bougienage is safe and effective treatment for the majority of stricture patients, with surgery being reserved for the subset of patients with intractable esophagitis, irreversibly damaged esophagus, or extra-esophageal manifestations.

Diagnosis and management of peptic esophageal strictures.

Peptic strictures of the esophagus are a common sequelae of long-standing reflux esophagitis. They occur in approximately 10% of patients with gastroesophageal reflux disease seeking medical evaluation. Factors predisposing to stricture formation are poorly understood; however, stricture patients are typically older, have a longer duration of reflux symptoms, and more frequently display abnormal esophageal motility than reflux patients without strictures. Diagnosis can usually be made with a careful history but should be confirmed with a barium esophagram followed by endoscopy with biopsies to exclude malignancy. Relief of dysphagia, which is the initial goal of therapy, can be readily accomplished in most patients using polyethylene or mercury-filled dilators or balloons. An equally important therapeutic objective should be the complete healing of associated esophagitis using proton pump inhibitors. Surgical treatment is reserved for the subset of patients with intractable esophagitis, irreversibly damaged esophagus, or extraesophageal manifestations.

Preoperative radiation therapy for carcinoma of the esophagus.

From 1960 through 1973, 415 patients with carcinoma of the esophagus were treated with radiation therapy. Three hundred and thirty-two patients had planned preoperative irradiation to a dose of 4500 rads in 18 fractions, and 101 of these had subsequent resections with either colon or stomach replacement. The operative mortality in this group was 18% and the 2- and 5-year survivals were 22.8 and 13.6%, respectively. The dose of 4500 rads in 18 fractions produced tumor sterilization in 3% and reduction to in situ carcinoma in 10% of these 101 patients. The survival was considerably improved in this small group of patients. Those patients not amenable to exploration had a 3% 5-year and a 5.6% 2-year survival was 12.1%. The overall survival was 9% at 2 years and 6% at 5 years. The results in this series are compared with the most recent reports in the literature.

Chronic radiation myelitis.

From March 1971 to September 1973, 200 patients with primary bronchogenic carcinoma received 4,000 rad (40 Gy) by means of split-course accelerated fractionation. Forty-five patients (22.5%) survived more than 11 months; and of these, 6 (13.3%) were found to have progressive myelitis. Recent reports indicate that rapid fractionation is preferred in some centers and may be undergoing a resurgence. The authors review their experience with this technique and the current understanding of the factors which affect the development of radiation myelitis.

Radition therpay control of nine patients with malignant thymoma.

Malignant thymoma is a relatively rare condition and a review of the literature reveals approximately 100 reported cases. Only a small percentage of these have been treated with megavoltage radiation therapy; therefore, it is difficult to find the necessary information to establish a proper time-dose relationship for treatment. This report deals with the radiation therapy and survival data concerning nine patients treated for malignant thymoma during a ten year period at the Medical University of South Carolina. Megavoltage irradiation in the dose range of 3500-4800 rads was employed in all patients. All gross tumor was completely resected in only three patients, two had a biopsy only, and the remaining four had subtotal resections. Local tumor control has been 100% with the average follow-up being 5.5 years and a minimum of 30 months. Three patients are dead; one from intercurrent disease, one from myasthenia gravis, and one from radiation injury to the spinal cord. One patient is alive with metastatic disease controlled by chemotherapy. The technique of radiation therapy is outlined, as well as suggested treatment policy.

Gross and microscopic findings in the human esophagus after esophageal variceal band ligation: a postmortem analysis.

Endoscopic sclerotherapy has been the therapy of choice for controlling acute variceal hemorrhage. Recently, endoscopic band ligation has been utilized for the management of esophageal varices with fewer complications and greater efficacy. We report the pathologic findings in the human esophagus 5 days after esophageal variceal band ligation.