Chirurgische Therapie des Ösophaguskarzinoms: Eine prospektive 20-Jahres-Analyse

Zusammenfassung

Hintergrund: Ziel unserer Studie war die Analyse von Langzeitentwicklungen der chirurgischen Therapie des Ösophaguskarzinoms in unserer Klinik über einen Zeitraum von 20 Jahren mit differenzierter Betrachtung der beiden vorherrschenden histologischen Tumortypen. Patienten und Methodik: Zwischen September 1985 und September 2005 wurden in unserer Klinik 470 Patienten wegen eines malignen Tumors der Speiseröhre ösophagusreseziert. Die abdomino-thorakale Ösophagusresektion mit abdomineller und erweiterter mediastinaler Lymphknotendissektion sowie intrathorakaler Anastomose war der Standardeingriff beim Plattenepithelkarzinom, während beim Adenokarzinom eine transhiatale Resektion mit abdomineller und hinterer mediastinaler Lymphadenektomie und zervikaler Ösophagogastrostomie erfolgte. Der Beobachtungszeitraum von 20 Jahren wurde zur Analyse von Entwicklungen in 2 Intervalle eingeteilt: Intervall 1 von 9 / 1985 bis 9 / 1995 und Intervall 2 von 10 / 1995 bis 9 / 2005. Ergebnisse: Beide Tumorentitäten wiesen im letzten Intervall (10 / 1995-9 / 2005) signifikant frühere Tumorstadien auf. Bei in beiden Intervallen proportional identischem Anteil an transthorakalen Resektionen beim Plattenepithelkarzinom zeigte sich ein signifikanter Trend zum transhiatalen Vorgehen beim Adenokarzinom in der letzten Dekade (3,6 % im Zeitraum zwischen 9 / 1985 und 9 / 1995 im Vergleich zu 23,6 % zwischen 10 / 1995 und 9 / 2005) (p < 0,05). Während die Gesamtprognose beim Plattenepithelkarzinom in beiden Dekaden nicht signifikant verschieden war (p = 0,2040), fand sich bei Patienten mit Adenokarzinom in der letzten Dekade ein signifikant besseres Langzeitüberleben (Log-Rank-Test: p = 0,0365). Die Prognose beim Adenokarzinom konnte somit im zeitlichen Verlauf mit einer 3-Jahres-Überlebensrate von zuletzt 40 % (verglichen mit 17,5 % in der ersten Dekade) und einer 5-Jahres-Überlebensrate von 25 % (verglichen mit 15 %) verbessert werden. Folgerung: Die chirurgische Therapie des Ösophaguskarzinoms hat in den letzten 20 Jahren deutliche Veränderungen erfahren. Diese sind überwiegend durch epidemiologische und diagnostische Aspekte, eine verbesserte Patientenselektion durch ein dem Tumorstadium und dem individuellen operativen Risiko des Patienten angepasstes operatives Vorgehen bedingt und haben insbesondere beim Adenokarzinom des Ösophagus zu einer signifikant günstigeren Langzeitprognose geführt.

Abstract

Background: The aim of our study was the analysis of long-term developments in the surgical therapy for esophageal carcinoma at our hospital over a period of 20 years with a differentiated view on the two predominant histological tumour types. Patients and Methods: Between September 1985 and September 2005, esophageal resections were performed in 470 patients at our clinic on account of a malignant tumour of the esophagus. The abdomino-thoracic resection with abdominal and extended mediastinal lymph node dissection as well as intrathoracic anastomosis was the standard treatment in the case of squamous cell carcinoma, whereas in adenocarcinoma a transhiatal resection with abdominal and dorsal mediastinal lymphadenectomy and cervical esophagogastrostomy was carried out. For analysis of the development, the study period of 20 years was divided into two intervals: interval 1 from 9 / 1985 to 9 / 1995, and interval 2 from 10 / 1995 to 9 / 2005. Results: Both tumour entities displayed in the last interval (10 / 1995 to 9 / 2005) significantly earlier tumour stages. A proportionally identical amount of transhiatal resections for squamous cell carcinoma was found in both intervals, whereas the transhiatal procedures for adenocarcinoma increased in the last decade (3.6 % in the period between 9 / 1985 and 9 / 1995, as compared with 23.6 % between 10 / 1995 and 9 / 2005) (p < 0.05). While the overall prognosis for squamous cell carcinoma did not significantly differ in the two decades (p = 0.2040), patients with adenocarcinoma were found to have a significantly improved long-term survival (log-rank test: p = 0.0365) in the second decade. The prognosis for adenocarcinoma, therefore, could be improved in the course of time with a 3-year survival rate of finally 40 % (as compared with 17.5 % in the first decade), and a 5-year survival rate of 25 % (as compared with 15 %). Conclusion: Surgical therapy for esophageal carcinoma has undergone distinct changes over the past 20 years. These are mainly due to epidemiological and diagnostic aspects, an improved selection of patients, whereby the operative procedure is adapted to the tumour stage and the operative risk for the patient. Especially with adenocarcinoma of the esophagus, these changes have led to a significantly more favourable long-term prognosis.

operative Therapie des Ösophaguskarzinoms - Langzeitentwicklungen - 20-Jahres-Analyse - Plattenepithelkarzinom - Adenokarzinom

surgical therapy of esophageal carcinoma - long-term developments - 20-year analysis - squamous cell carcinoma - adenocarcinoma

Literatur

• 1 Ando N, Ozawa S, Kitagawa Y, Shinozawa Y, Kitajima M. Improvement in the results of surgical treatment of advanced squamous esophageal carcinoma during 15 consecutive years.  Ann Surg. 2000;  232 225-232
• 2 Bergman J J, Tytgat G N. New developments in the endoscopic surveillance of Barrett's esophagus.  Gut. 2005;  54 (Suppl 1) S 38-S 42
• 3 Bollschweiler E, Schroder W, Holscher A H, Siewert J R. Preoperative risk analysis in patients with adenocarcinoma or squamous cell carcinoma of the esophagus.  Br J Surg. 2000;  87 1106-1110
• 4 Bollschweiler E, Wolfgarten E, Gutschow C, Holscher A H. Demographic variations in the rising incidence of esophageal adenocarcinoma in white males.  Cancer. 2001;  92 549-555
• 5 Botterweck A A, Schouten L J, Volovics A, Dorant E, van den Brandt P A. Trends in incidence of adenocarcinoma of the oesophagus and gastric cardia in ten European countries.  Int J Epidemiol. 2000;  29 645-654
• 6 Blot W J, Devesa S S, Kneller R W, Fraumeni J FJ. Rising incidence of adenocarcinoma of the esophagus and gastric cardia.  JAMA. 1991;  265 1287-1289
• 7 Connor M J, Sharma P. Chromoendoscopy and magnification endoscopy for diagnosing esophageal cancer and dysplasia.  Thorac Surg Clin. 2004;  14 87-94
• 8 Cox D R. Regression models and life tables.  J R Stat Soc. 1972;  34 187-220
• 9 Devesa S S, Blot W J, Fraumeni J F. Changing patterns in the incidence of esophageal and gastric carcinoma in the United States.  Cancer. 1998;  83 2049-2053
• 10 Doty J R, Salazar J D, Forastiere A A, Heath E I, Kleinberg L, Heitmiller R F. Postesophagectomy morbidity, mortality, and length of hospital stay after preoperative chemoradiation therapy.  Ann Thorac Surg. 2002;  74 227-231
• 11 Ellis Jr F H, Heatley G J, Krasna M J, Williamson W A, Balogh K. Esophagogastrectomy for carcinoma of the esophagus and cardia: a comparison of findings and results after standard resection in three consecutive eight-year intervals with improved staging criteria.  J Thorac Cardiovasc Surg. 1997;  113 836-846
• 12 Fiorica F, Di Bona D, Schepis F. Preoperative chemoradiotherapy for oesophageal cancer: A systemic review and meta-analysis.  Gut. 2004;  53 925-930
• 13 Gockel I, Exner C, Junginger T. Morbidity and mortality after esophagectomy for esophageal cancer: a risk analysis.  World J Surg Oncol. 2005;  3 37
• 14 Gockel I, Heckhoff S, Messow C M, Kneist W, Junginger T. Transhiatal and transthoracic resection in adenocarcinoma of the esophagus: Does the operative approach have an influence on the long-term prognosis?.  World J Surg Oncol. 2005;  3 40
• 15 Gockel I, Kneist W, Junginger T. Incurable esophageal cancer: patterns of tumor spread and therapeutic consequences.  World J Surg. 2006;  30 183-190
• 16 Goetz M, Hoffman A, Galle P R, Neurath M F, Kiesslich R. Confocal laser endoscopy: new approach to the early diagnosis of tumors of the esophagus and stomach.  Future Oncol. 2006;  2 469-476
• 17 Herskovic A, Martz K, Al-Sarraf M, Leichman L, Brindle J, Vaitkevic V, Cooper J, Byhardt R, Davis L, Emami B. Combined chemotherapy and radiotherapy compared with radiotherapy alone in patients with cancer of the esophagus.  N Engl J Med. 1992;  11 1593-1598
• 18 Hofstetter W, Swisher S G, Correa A M, Hess K, Putnam Jr J B, Ajani J A, Dolormente M, Francisco R, Komaki R R, Lara A, Martin F, Rice D C, Sarabia A J, Smythe W R, Vaporciyan A A, Walsh G L, Roth J A. Treatment outcomes of resected esophageal cancer.  Ann Surg. 2002;  236 376-384
• 19 Hulscher J BF, Tijssen J GP, Obertop H, van Lanschot J JB. Transthoracic versus transhiatal resection for carcinoma of the esophagus: a meta-analysis.  Ann Thorac Surg. 2001;  72 306-313
• 20 Hulscher J B, van Sandick J W, de Boer A G, Wijnhoven B P, Tijssen J G, Fockens P, Stalmeier P F, Ten Kate F J, van Dekken H, Obertop H, Tilanus H W, van Lanschot J J. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus.  N Engl J Med. 2002;  347 1662-1669
• 21 Junginger T, Dutkowski P. Selective approach to the treatment of esophageal cancer.  Br J Surg. 1996;  83 1473-1477
• 22 Junginger T, Gockel I, Heckhoff S. A comparison of transhiatal and transthoracic resections on the prognosis in patients with squamous cell carcinoma of the esophagus.  Eur J Surg Oncol. 2006;  32 749-755
• 23 Kaplan E, Meier P. Non-parametric estimation from incomplete observations.  J Am Stat Assoc. 1958;  53 457-481
• 24 Kneist W, Schreckenberger M, Bartenstein P, Menzel C, Oberholzer K, Junginger T. Prospective evaluation of positron emission tomography in the preoperative staging of esophageal carcinoma.  Arch Surg. 2004;  139 1043-1049
• 25 Kubo A, Corley D A. Marked multi-ethnic variation of esophageal and gastric cardia carcinomas within the United States.  Am J Gastroenterol. 2004;  99 582-588
• 26 Kubo A, Corley D A. Marked regional variation in adenocarcinomas of the esophagus and the gastric cardia in the United States.  Cancer. 2002;  95 2096-2102
• 27 Law S, Kwong D L, Kwok K F, Wong K H, Chu K M, Sham J S, Wong J. Improvement in treatment results and long-term survival of patients with esophageal cancer: impact of chemoradiation and change in treatment strategy.  Ann Surg. 2003;  238 339-347
• 28 Mashimo H, Wagh M S, Goyal R K. Surveillance and screening for Barrett esophagus and adenocarcinoma.  J Clin Gastroenterol. 2005;  39 (Suppl. 2) S 33-S 41
• 29 Pohl H, Welch H G. The role of overdiagnosis and reclassification in the marked increase of esophageal adenocarcinoma.  J Natl Cancer Inst. 2005;  97 142-146
• 30 Sampliner R E. Managing Barrett's esophagus: what is new in 2005?.  Dis Esophagus. 2005;  18 17-20
• 31 Siewert J R, Feith M, Werner M, Stein H J. Adenocarcinoma of the esophagogastric junction: results of surgical therapy based on anatomical / topographic classification in 1,002 consecutive patients.  Ann Surg. 2000;  232 353-361
• 32 Siewert J R, Stein H J, Feith M, Bruecher B L, Bartels H, Fink U. Tumor cell type is an independent prognostic parameter in esophageal cancer: lessons learned from more than 1000 consecutive resections at a single institution in the Western world.  Ann Surg. 2001;  234 360-369
• 33 Urschel J D, Vasan H B. A meta-analysis of randomized controlled trials that compared neo-adjuvant chemoradiation and surgery to surgery alone for resectable esophageal cancer.  Am J Surg. 2003;  185 538-543