Resection for advanced cancer of the thoracic esophagus: cervical or thoracic anastomosis? Late results of a prospective randomized study

Abstract

During a 2 1/2-year period, 60 consecutive patients with cancer of the thoracic esophagus were randomized to undergo a cervical or thoracic anastomosis. The tumors were staged postoperatively (stage I, n = 2; stage II, n = 19; stage III, n = 9; and stage IV, n = 30) and were almost equally distributed between the two groups. The upper limit of three tumors was above the convexity of the aortic arch. The esophageal specimens were studied with regard to measurements of the tumor and of the resected esophagus. The microscopic aspects were evaluated by serial sections after vital staining. The prevalence of ignored plurifocal cancers, of submucosal infiltrations, and of distant areas of dysplasia in both groups was confirmed. Malignant invasions of esophageal sections were more frequent in patients undergoing thoracic anastomosis (10 versus 3), and diseased upper mediastinal lymph nodes were more frequent in those undergoing cervical anastomosis (17 versus 7). Mortality was equally divided between the two groups. Respiratory complications and recurrent laryngeal trauma were more frequent in patients having cervical anastomosis. Long-term survivors had stage N0 disease, with a healthy esophageal section. Even though subtotal esophagectomy reduces the prevalence of microscopic esophageal wall invasion above the tumor and allows more complete unilateral exploration and resection of invaded lymph nodes, it offers no significant benefit concerning survival of patients with advanced cancer and malignant lymphadenopathy.