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Intraoperative radiation therapy to the upper mediastinum and nerve‐sparing three‐field lymphadenectomy followed by external beam radiotherapy for patients with thoracic esophageal carcinoma
Author(s) -
Hosokawa Masao,
Shirato Hiroki,
Ohara Masanori,
Kagei Kenji,
Hashimoto Seiko,
Nishino Shigeo,
Takamura Akio,
Arimoto Takuro
Publication year - 1999
Publication title -
cancer
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 3.052
H-Index - 304
eISSN - 1097-0142
pISSN - 0008-543X
DOI - 10.1002/(sici)1097-0142(19990701)86:1<6::aid-cncr3>3.0.co;2-9
Subject(s) - medicine , mediastinum , radiation therapy , surgery , lymphadenectomy , dissection (medical) , esophageal cancer , carcinoma , radiology , lymph node , cancer
Abstract BACKGROUND In patients with thoracic esophageal carcinoma, radical dissection of the upper mediastinal lymph nodes often leads to complications such as recurrent laryngeal nerve palsy and subsequent pulmonary disorders. Intraoperative radiation therapy (IORT) to the upper mediastinum and nerve‐sparing three‐field lymphadenectomy followed by external beam radiotherapy has been developed to improve the locoregional control rate without resulting in these major postoperative complications. METHODS Three‐field lymphadenectomy, including cervical, mediastinal, and abdominal lymph node dissection, was performed. Dissection of the upper mediastinum was conservative to preserve recurrent laryngeal nerve function. IORT of 12‐25 grays (Gy) was applied to the upper mediastinum. Postoperative radiation therapy (PORT) of 45 Gy in 16 fractions over 4 weeks was applied to the entire neck and upper mediastinum using an external X‐ray beam. Between 1989‐1996, 121 patients with thoracic esophageal carcinoma underwent surgery and received IORT, and 103 of these patients underwent PORT as part of their treatment schedule. RESULTS The surgical mortality rate was 0.8% (1 of 121 cases). The overall 5‐year survival rate was 34.4% and the cause specific 5‐year survival rate was 54.8%. The cause specific 5‐year survival rate for pN0 tumors was 79.4% and was 43.8% for pN1 tumors. No patients died with locoregional recurrence in the mediastinal lymph nodes. Recurrent laryngeal nerve palsy was observed in 25 patients (21%), but the palsy remained for > 1 month in only 13 patients (11%). Mechanical ventilation support for > 48 hours was required for 22 patients (18.2%). Fatal tracheal ulcers occurred in 4 of 18 patients who received the highest IORT dose of 25 Gy. CONCLUSIONS Three‐field lymphadenectomy to preserve recurrent laryngeal nerves and IORT using 12‐20 Gy followed by 45‐Gy PORT effectively reduced locoregional recurrence, recurrent laryngeal nerve palsy, and pulmonary complications caused by radical surgical dissections. The minimally effective dose of IORT appears to be ≤ 15 Gy, a factor that will be further evaluated with longer follow‐up. Cancer 1999;86:6–13. © 1999 American Cancer Society.