New multi-disciplinary treatment modality with RALS for patients with esophageal cancer.

Esophageal cancer is frequently found when it is already in the advanced stage and curative surgery for such cases is consequently difficult to perform. The new multi-disciplinary treatment for esophageal cancer presented here was, therefore, conceived to improve both the survival rate and quality of life of these patients. This combined treatment modality consists of limited surgery, external irradiation, intracavitary irradiation with remote-controlled after-loading system (RALS) and peri-operative chemotherapy. In the present series, 45 patients with esophageal cancer received esophagectomy and on another 11 patients bypass operation was performed. All patients were treated with this multi-disciplinary treatment after operation. A 3 cm-wide thin gastric tube was made from the greater curvature of the stomach of the patient using an autosuture apparatus (PLC55 or GIA). In the bypass operation, the jejunum was anastomosed to the original esophagus in the Roux-en Y fashion and jejunostomy was performed on the oral side of the Roux loop. A silastic tube of 9 mm inner diameter was inserted from the jejunostomy and placed into the original esophagus for the purpose of postoperative intracavitary irradiation with RALS. For the patients receiving esophagectomy, a similar silastic tube was also placed in the posterior mediastinum for intracavitary irradiation with RALS. The indication of the bypass operation was i) a tumor length longer than 9 cm on the X-ray film and/or ii) direct invasion to the aortic wall evident by CT or MRI examination. Two weeks after the operation, external irradiation to the mediastinum with Linac 10 MV X-ray, and to the bilateral cervical regions with Linac 15 MeV electron beam, was started. The irradiation doses were 30 Gy (2 Gy/day, 5 times/ week) and 48 Gy (4 Gy/day, 3 times/week), respectively. The intracavitary irradiation with RALS was started shortly before the end of the external irradiation period and was delivered from a 60Co source. The total dose was 24 Gy (6 Gy/day, once a week) for the esophagectomized cases, and 18 Gy for the bypassed cases. Two or three weeks after the termination of the radiotherapy, chemotherapy with cisplatinum and 5-fluorouracil was performed and repeated every 6 months for 2 years. All patients could eat normally and were discharged after finishing the first chemotherapy session. The overall 5-year survival rate was 49% for the esophagectomized cases and 11% for the bypassed cases. The longest survival time in the bypassed cases was 5 years and 4 months. Neither operative death nor severe complications were experienced during the treatment period. The results indicate that this newly developed multi-disciplinary treatment with RALS can improve the prognosis and the quality of life not only in the esophagectomized patients but also in the bypassed patients with advanced esophageal cancer.