Ann Thorac Surg 1998;65:1534
© 1998 The Society of Thoracic Surgeons
Original articles: general thoracic
Invited commentary
Mark B. Orringer, MDa
a Section of Thoracic Surgery, University of Michigan, Taubman Health Care Center, 1500 E Medical Center Dr, 2120TC, Box 0344, Ann Arbor, MI 48109, USA
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Invited commentary
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 Invited commentary
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This report by Poon and associates has documented a 9.5% incidence of nonesophageal primary cancers, 70% of which are aerodigestive tract cancers, in patients with esophageal squamous cell carcinoma. The thoroughness of the follow-up (93.6% complete) of their 1,055 patients with esophageal cancer that allowed identification of 114 nonesophageal primary cancers is admirable, as is the ability of the Hong Kong Cancer Registry to provide reliable incidence rates of various cancers as well as the relative risk of having another nonesophageal cancer in patients with esophageal cancer compared with the general population. That 1% to 2% of patients with head and neck cancers have metachronous or synchronous esophageal cancer has been fairly well established, and virtually all such tumors are squamous cell carcinomas. This report by Poon and associates, however, is one of few to address the incidence of other cancers in patients with esophageal squamous cell carcinoma. Interestingly, 47% of these patients with multiple primary cancers had antecedent nonesophageal primary cancers diagnosed 6 months or more before the esophageal cancer, and 43% had synchronous (occurring within 6 months of the diagnosis of the esophageal cancer) cancers. Of the synchronous tumors, 87% were aerodigestive cancers, whereas of the antecedent or subsequent tumors, only 60% were of the aerodigestive type. Not surprisingly, patients with multiple primary cancers had significantly greater histories of alcohol and tobacco use. Given the known generally poor survival in most patients with esophageal cancer, it is also not surprising that the overall survival of patients with antecedent tumors, synchronous tumors, or esophageal squamous cell carcinoma without other tumors was not significantly different (median survival being 8.6, 8.5, and 8.8 months, respectively); the prognosis in all of these groups is determined by the esophageal carcinoma.
This report raises some interesting issues. Esophageal surgeons are inevitably confronted with a patient who has both esophageal cancer and either a head and neck or lung cancer. In the absence of mediastinal adenopathy or other evidence of metastatic disease on the staging evaluation, the patient should be given the "benefit of the doubt" that he or she has two separate primary cancers and not metastatic disease. It is not unreasonable to approach each tumor surgically when possible, but thought should be given to "who goes first." In the patient with both a resectable lung and esophageal cancer, simultaneous transthoracic resections may be possible. In patients with both head and neck and esophageal carcinoma, if possible, the esophagectomy should precede by several weeks radical dissections of the floor of the mouth, tongue, and neck that may result in impaired swallowing and resultant aspiration that might jeopardize a subsequent esophageal resection and reconstruction. For the same reason, when a head and neck primary cancer occurs synchronously with lung cancer, I generally approach the lung cancer first, delaying for several weeks the head and neck resection, which may cause aspiration that would delay or preclude the pulmonary resection. Synchronous laryngeal or postcricoid squamous cell carcinoma and intrathoracic esophageal carcinoma may be resected en bloc with a larygopharyngectomy and transhiatal esophagectomy, restoring alimentary continuity with a colonic interposition.
Although Poon and associates’ data suggest that panendoscopy in the patient with esophageal cancer is indicated to identify associated aerodigestive tract primary cancers, it is unlikely that in patients with esophageal adenocarcinoma the yield of other cancers will be great enough to justify a similar approach. Gastroesophageal reflux and secondary Barrett’s metaplasia, not cigarette smoking and alcohol abuse, is the cause of the current epidemic of esophageal adenocarcinoma in North America and Europe.
The "message" that esophageal squamous cell carcinoma, often found against the backdrop of cigarette smoking and alcohol abuse, may not occur in isolation of other primary cancers is an important one. Surveillance for other aerodigestive tract cancers during the preoperative evaluation of these patients and postoperative follow-up of this high-risk population with periodic sputum cytologies and chest radiographs are warranted.
