Ann Thorac Surg 2003;76:1742-1743
© 2003 The Society of Thoracic Surgeons
Case report
Management of late distant metastases after trimodality therapy for esophageal cancer
You Sheng Mao, MDa,
Mohan Suntharalingam, MDa,
Mark J. Krasna, MD*a
a Division of Thoracic Surgery, University of Maryland Medical System, Baltimore, Maryland, USA
Accepted for publication March 25, 2003.
* Address reprint requests to Dr Krasna, Division of Thoracic Surgery, University of Maryland Medical System, 22 South Greene St, Room N4E35, Baltimore, MD, USA 21201
e-mail: mkrasna{at}smail.umaryland.edu
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Abstract
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Trimodality therapy has been shown in preliminary studies to increase survival in esophageal cancer. Distant recurrence remains the main pattern of failure. A case of aggressive treatment of two metachronous solitary visceral metastases is presented.
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Introduction
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Recent reports have suggested improved survival with combined modality therapy in esophageal cancer [1]. The pattern of failure remains one of distant recurrence. We describe a patient with esophageal cancer who had aggressive treatment of two late metachronous, solitary, visceral metastases.
A 64-year-old white male physician presented in 1993 with dysphagia and regurgitation with cold beverages and weight loss. The patient was found to have an esophageal mass by upper endoscopy, which was located at 36 to 44 cm from the incisors. Biopsy showed poorly differentiated adenocarcinoma with signet ring cells. The computed tomographic scan and magnetic resonance image (MRI) revealed a Stage II (T2N0M0) lesion with no involvement of surrounding tissue or evidence of enlarged lymph nodes in the chest and abdomen. The patient opted to undergo preoperative chemotherapy and radiation therapy followed by surgery. Concomitant chemotherapy and radiotherapy consisted of 5,040 Gy over 28 fractions and two cycles of concurrent cisplatin (100 mg/M2) on day 1 and 5-fluorouracil (1 g/M2) was given on days 2 through 5. After 3 weeks of recovery from the management protocol, the patient was restaged by computed tomographic scan, which showed clinical response to therapy. He then underwent an Ivor-Lewis esophagogastrectomy in December 1993. The pathology report of the resected specimen showed ulceration with residual microscopic adenocarcinoma involving the smooth muscle wall and marked transmural edema and vascular luminal narrowing typical of radiation change. After surgery, the patient received two courses of chemotherapy including VP-16 (120 mg/M2) and leucovorin (300 mg) as well as 5-fluorouracil (500 mg) on days 1 through 3.
In May 1995, the patient presented with dizziness and progressive worsening of his gait with occipital and retro-orbital headaches, difficulty reading, and confusion as well as slurred speech. A computed tomographic scan of the head demonstrated extensive edema and a mass effect in the left cerebellar hemisphere causing obliteration of the fourth ventricle (Figs 1A, 1B) was noted on MRI.
He was admitted and subsequently underwent gross total resection of a 4-cm lesion of the left cerebellum, which was demonstrated as adenocarcinoma by pathology consistent with the esophageal primary. After craniotomy he received whole brain radiation to a total of 40 Gy with no complications. In July 1996, a follow-up routine computed tomographic scan of the abdomen showed a 3 x 3.5 x 5 cm solitary mass in the upper pole of the right kidney with no additional evidence of metastasis (Fig 2). He then underwent a right nephrectomy with curative resection. Pathology again showed an adenocarcinoma consistent with the esophageal primary.
At the last follow-up in October 2002, no evidence of thoracic, abdominal, or brain metastasis was noted, and the patient’s functional status was excellent. The patient has now survived more than 9 years since his initial treatment and currently has no clinical endoscopic or radiographic evidence of recurrent disease.
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Comment
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This case of stage II esophageal adenocarcinoma with distant, metachronous, solitary metastasis to the brain and kidney was successfully treated by combination therapy including chemotherapy, radiotherapy, and surgery. Patients with esophageal cancer usually are not treated aggressively in the presence of distant organ metastasis. Solitary metastasis is felt to occur with occult blood and lymph node metastasis. It has been reported that esophageal cancer patients usually present recurrence within 2 years; systemic metastasis could occur as often as 26% after curative resection within 20 months of follow-up [2]. Brain metastasis has only been reported in 3.5% of all resected patients and kidney metastasis in only 1.0% [3, 4]. This patient presented with metastasis to the brain 1.5 years postresection and to the right kidney 2.5 years after his initial treatment for esophageal carcinoma.
The decision to resect metastatic disease depends on the patient’s functional status, the status of the primary tumor, the size of the metastatic tumor, the location of the recurrence, and the time interval of the so-called solitary metastasis occurrence. If the patient has good overall function and no local recurrence of primary tumor, solitary metastasis that occurs in a well-confined organ that can be resected completely without severe dysfunction, and that is at least 1 year after the initial treatment for primary esophageal carcinoma, then using combined modality aggressive treatment may be appropriate. De-spite pre-resection chemoradiation, this patient unfortunately still had two metachronous solitary metastases develop. Recently several articles have reported that preoperative chemotherapy or chemoradiation can prolong survival in patients with a complete pathologic response [1, 5]. Whether systemic therapy will result in improved survival and reduced distant metastases remains to be seen [6, 7]. We are currently completing a phase II prospective trial of neoadjuvant chemoradiation with postresection high-dose Taxotere for patients with esophageal cancer. This underscores the importance of carefully selecting those esophageal cancer patients who will likely respond to these regimens and the importance of identifying subgroups by further investigation, such as preoperative pathologic staging and molecular biological prognosticators for survival as indicators for allocation of treatment [8].
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References
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- Suntharalingam M., Haas M., Sonett J., et al. Accurate lymph node assessment prior to trimodality therapy for esophageal carcinoma. Cancer J 2001;7(6):509-515.[Medline]
- Law S.Y., Fox M., Wong J. Pattern of recurrence after esophageal resection for cancer: clinical implications. Br J Surg 1996;83(1):107-111.[Medline]
- Gabrielsen T.O., Eldevik O.P., Orringer M.B., Marshall B.L. Esophageal carcinoma metastatic to the brain: clinical value and cost-effectiveness of routine enhanced head CT before esophagectomy. Am J Neuroradiol 1995;16(9):1915-1921.[Abstract]
- Quint L.E., Hepburn L.M., Francis I.R., White I.R., Orringer M.B. Incidence and distribution of distant metastases from newly diagnose esophageal carcinoma. Cancer 1995;76(7):1120-1125.[Medline]
- Vogel S.B., Mendenhall W.M., Sombeck M.D., Marsh R., Woodward E.R. Downstaging of esophageal cancer after preoperative radiation and chemotherapy. Ann Surg 1995;221(6):685-693.[Medline]
- Ando N., Iizuka T., Kakegawa T., et al. A randomized trial of surgery with and without chemotherapy for localized squamous carcinoma of the thoracic esophagus: the Japan clinical oncology group study. J Thorac Cardiovasc Surg 1997;114:205-209.[Abstract/Free Full Text]
- Law S., Fox M., Chow S., Chu K., Wong J. Preoperative chemotherapy alone for squamous cell carcinoma of the esophagus: a prospective randomized trial. J Thorac Cardiovasc Surg 1997;114:210-217.[Abstract/Free Full Text]
- Skinner D. Editorial on combined therapy for squamous cell carcinoma of esophagus. J Thorac Cardiovasc Surg 1997;114:203-204.[Free Full Text]
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Abstract
Introduction
