Esophageal Cancer
http://www.100md.com
《新英格兰医药杂志》
To the Editor: Enzinger and Mayer (Dec. 4 issue)1 provide an extensive review of esophageal cancer. However, they fail to mention one very important aspect of care that is routinely assessed in the United Kingdom2: nutritional support of patients at the time of presentation. A body-mass index (the weight in kilograms divided by the square of the height in meters) that is less than 18.5, a body weight that is less than 90 percent of the predicted value, and a low albumin level have all been shown to increase the risk of perioperative complications. Nutritional support, given either enterally3 or parenterally,4 should be used to optimize patients' fitness before and during treatment.
Faiyaz Mohammed, M.B., B.S.
Trafford General Hospital
Manchester M41 5SL, United Kingdom
safai@hotmail.com
References
Enzinger PC, Mayer RJ. Esophageal cancer. N Engl J Med 2003;349:2241-2252.
Allum WH, Griffin SM, Watson A, Colin-Jones D. Guidelines for the management of oesophageal and gastric cancer. Gut 2002;50:Suppl V:v1-v23.
Bozzetti F, Cozzaglio L, Gavazzi C, et al. Nutritional support in patients with cancer of the esophagus: impact on nutritional status, patient compliance to therapy, and survival. Tumori 1998;84:681-686.
Daly JM, Massar E, Giacco G, et al. Parenteral nutrition in esophageal cancer patients. Ann Surg 1982;196:203-208.
To the Editor: Enzinger and Mayer state that esophageal squamous-cell cancer that is not clinically suspected is incidentally detected in approximately 1 to 2 percent of patients with head and neck cancers. In contrast to this moderate percentage, obtained by retrospective analysis, prospective clinical studies in France, Germany, Brazil, and Japan have consistently shown that 6 to 14 percent of patients with head and neck cancer already harbor or eventually have invasive esophageal squamous-cell cancer.1 Similarly, the risk of esophageal squamous-cell cancer may be as high as 3.3 to 8.2 percent in persons with a history of heavy alcohol and tobacco consumption.2 The survival benefit achieved by screening for and treating early esophageal neoplasia3 underlines the efficacy of surveillance in groups at very high risk. Moreover, effective chemoprevention is needed for persons at high risk for multifocal (and metachronous) esophageal squamous-cell cancer.4 By combining endoscopic surveillance and effective chemoprevention, we hope to improve the prognosis for patients with this debilitating disease, at least in groups known to be at high risk.
Hans Scherübl, M.D.
Martin Zeitz, M.D.
Charité–Universit?tsmedizin Berlin
12200 Berlin, Germany
hans.scheruebl@charite.de
References
Scherübl H, von Lampe B, Faiss S, et al. Screening for oesophageal neoplasia in patients with head and neck cancer. Br J Cancer 2002;86:239-243.
Scherübl H, Sutter AP, Zeitz M. NSAIDs and esophageal cancer. Gastroenterology 2003;125:1914-1915.
Horiuchi M, Makuuchi H, Machimura T, Tamura Y, Sakai M. Survival benefit of screening for early oesophageal carcinoma in head and neck cancer patients. Dig Endosc 1998;10:110-5.
Corley DA, Kerlikowske K, Verma R, Buffler P. Protective association of aspirin/NSAIDs and esophageal cancer: a systematic review and meta-analysis. Gastroenterology 2003;124:47-56.
To the Editor: In their article on esophageal cancer, Enzinger and Mayer do not discuss photodynamic therapy in the treatment of high-grade dysplasia and early adenocarcinoma in patients with Barrett's esophagus. Photodynamic therapy completely ablates high-grade dysplasia and most superficial adenocarcinomas, without the high morbidity and mortality associated with esophagectomy.1 Provided that staging can be performed accurately and more advanced disease can be ruled out, photodynamic therapy appears to be promising and merits discussion.2
Michael I. Argyres, M.D.
Ameripath–Colorado Pathology Consultants
Denver, CO 80218
margyres@ameripath.com
References
Wolfsen HC, Woodward TA, Raimondo M. Photodynamic therapy for dysplastic Barrett esophagus and early esophageal adenocarcinoma. Mayo Clin Proc 2002;77:1176-1181.
Wang KK. Current status of photodynamic therapy of Barrett's esophagus. Gastrointest Endosc 1999;49:S20-S23.
The authors reply: Drs. Scherübl and Zeitz suggest that the incidence of esophageal squamous-cell carcinoma as a second primary tumor in patients with a history of head and neck cancer may be as high as 14 percent in certain groups. Although the risk of esophageal squamous-cell cancer is increased in this clinical setting, an incidence of less than 1 percent has been reported in other series.1,2
Dr. Mohammed is correct in stating that nutrition may have a significant effect on the risk of perioperative complications in patients with esophageal cancer. In patients with clinically significant weight loss, nutritional support should be considered. We favor enteral nutrition over parenteral nutrition because enteral nutrition is less costly and more convenient, carries a lower risk of systemic infection, and is associated with better preservation of gut integrity.3,4
Dr. Argyres seeks to highlight the role of photodynamic therapy in the treatment of high-grade dysplasia and early adenocarcinoma in patients with Barrett's esophagus. We agree that such treatment (which we discuss along with other ablative options in our review) may be considered in patients for whom surgery is not an option. We have concerns, however, about accepting this strategy as equivalent to surgery, since 14 to 21 percent of T1 lesions are associated with spread to lymph nodes and endoscopic ultrasonography accurately predicts the T stage in only 80 to 90 percent of patients at centers of excellence.5 Moreover, as we state in our review, it is unknown at present whether ablative treatment to the mucosa, while eradicating the superficial dysplasia, reduces the eventual risk of cancer.
Peter C. Enzinger, M.D.
Robert J. Mayer, M.D.
Dana–Farber Cancer Institute
Boston, MA 02115
References
Ecimovic P, Pompe-Kirn V. Second primary cancers in laryngeal cancer patients in Slovenia, 1961-1996. Eur J Cancer 2002;38:1254-1260.
Gao X, Fisher SG, Mohideen N, Emami B. Second primary cancers in patients with laryngeal cancer: a population-based study. Int J Radiat Oncol Biol Phys 2003;56:427-435.
Ellis LM, Copeland EM III, Souba WW. Perioperative nutritional support. Surg Clin North Am 1991;71:493-507.
McClave SA, Snider HL, Spain DA. Preoperative issues in clinical nutrition. Chest 1999;115:Suppl:64S-70S.
Enzinger PC, Mayer RJ. Esophageal cancer. N Engl J Med 2003;349:2241-2252.
Faiyaz Mohammed, M.B., B.S.
Trafford General Hospital
Manchester M41 5SL, United Kingdom
safai@hotmail.com
References
Enzinger PC, Mayer RJ. Esophageal cancer. N Engl J Med 2003;349:2241-2252.
Allum WH, Griffin SM, Watson A, Colin-Jones D. Guidelines for the management of oesophageal and gastric cancer. Gut 2002;50:Suppl V:v1-v23.
Bozzetti F, Cozzaglio L, Gavazzi C, et al. Nutritional support in patients with cancer of the esophagus: impact on nutritional status, patient compliance to therapy, and survival. Tumori 1998;84:681-686.
Daly JM, Massar E, Giacco G, et al. Parenteral nutrition in esophageal cancer patients. Ann Surg 1982;196:203-208.
To the Editor: Enzinger and Mayer state that esophageal squamous-cell cancer that is not clinically suspected is incidentally detected in approximately 1 to 2 percent of patients with head and neck cancers. In contrast to this moderate percentage, obtained by retrospective analysis, prospective clinical studies in France, Germany, Brazil, and Japan have consistently shown that 6 to 14 percent of patients with head and neck cancer already harbor or eventually have invasive esophageal squamous-cell cancer.1 Similarly, the risk of esophageal squamous-cell cancer may be as high as 3.3 to 8.2 percent in persons with a history of heavy alcohol and tobacco consumption.2 The survival benefit achieved by screening for and treating early esophageal neoplasia3 underlines the efficacy of surveillance in groups at very high risk. Moreover, effective chemoprevention is needed for persons at high risk for multifocal (and metachronous) esophageal squamous-cell cancer.4 By combining endoscopic surveillance and effective chemoprevention, we hope to improve the prognosis for patients with this debilitating disease, at least in groups known to be at high risk.
Hans Scherübl, M.D.
Martin Zeitz, M.D.
Charité–Universit?tsmedizin Berlin
12200 Berlin, Germany
hans.scheruebl@charite.de
References
Scherübl H, von Lampe B, Faiss S, et al. Screening for oesophageal neoplasia in patients with head and neck cancer. Br J Cancer 2002;86:239-243.
Scherübl H, Sutter AP, Zeitz M. NSAIDs and esophageal cancer. Gastroenterology 2003;125:1914-1915.
Horiuchi M, Makuuchi H, Machimura T, Tamura Y, Sakai M. Survival benefit of screening for early oesophageal carcinoma in head and neck cancer patients. Dig Endosc 1998;10:110-5.
Corley DA, Kerlikowske K, Verma R, Buffler P. Protective association of aspirin/NSAIDs and esophageal cancer: a systematic review and meta-analysis. Gastroenterology 2003;124:47-56.
To the Editor: In their article on esophageal cancer, Enzinger and Mayer do not discuss photodynamic therapy in the treatment of high-grade dysplasia and early adenocarcinoma in patients with Barrett's esophagus. Photodynamic therapy completely ablates high-grade dysplasia and most superficial adenocarcinomas, without the high morbidity and mortality associated with esophagectomy.1 Provided that staging can be performed accurately and more advanced disease can be ruled out, photodynamic therapy appears to be promising and merits discussion.2
Michael I. Argyres, M.D.
Ameripath–Colorado Pathology Consultants
Denver, CO 80218
margyres@ameripath.com
References
Wolfsen HC, Woodward TA, Raimondo M. Photodynamic therapy for dysplastic Barrett esophagus and early esophageal adenocarcinoma. Mayo Clin Proc 2002;77:1176-1181.
Wang KK. Current status of photodynamic therapy of Barrett's esophagus. Gastrointest Endosc 1999;49:S20-S23.
The authors reply: Drs. Scherübl and Zeitz suggest that the incidence of esophageal squamous-cell carcinoma as a second primary tumor in patients with a history of head and neck cancer may be as high as 14 percent in certain groups. Although the risk of esophageal squamous-cell cancer is increased in this clinical setting, an incidence of less than 1 percent has been reported in other series.1,2
Dr. Mohammed is correct in stating that nutrition may have a significant effect on the risk of perioperative complications in patients with esophageal cancer. In patients with clinically significant weight loss, nutritional support should be considered. We favor enteral nutrition over parenteral nutrition because enteral nutrition is less costly and more convenient, carries a lower risk of systemic infection, and is associated with better preservation of gut integrity.3,4
Dr. Argyres seeks to highlight the role of photodynamic therapy in the treatment of high-grade dysplasia and early adenocarcinoma in patients with Barrett's esophagus. We agree that such treatment (which we discuss along with other ablative options in our review) may be considered in patients for whom surgery is not an option. We have concerns, however, about accepting this strategy as equivalent to surgery, since 14 to 21 percent of T1 lesions are associated with spread to lymph nodes and endoscopic ultrasonography accurately predicts the T stage in only 80 to 90 percent of patients at centers of excellence.5 Moreover, as we state in our review, it is unknown at present whether ablative treatment to the mucosa, while eradicating the superficial dysplasia, reduces the eventual risk of cancer.
Peter C. Enzinger, M.D.
Robert J. Mayer, M.D.
Dana–Farber Cancer Institute
Boston, MA 02115
References
Ecimovic P, Pompe-Kirn V. Second primary cancers in laryngeal cancer patients in Slovenia, 1961-1996. Eur J Cancer 2002;38:1254-1260.
Gao X, Fisher SG, Mohideen N, Emami B. Second primary cancers in patients with laryngeal cancer: a population-based study. Int J Radiat Oncol Biol Phys 2003;56:427-435.
Ellis LM, Copeland EM III, Souba WW. Perioperative nutritional support. Surg Clin North Am 1991;71:493-507.
McClave SA, Snider HL, Spain DA. Preoperative issues in clinical nutrition. Chest 1999;115:Suppl:64S-70S.
Enzinger PC, Mayer RJ. Esophageal cancer. N Engl J Med 2003;349:2241-2252.