Multimodality therapy for esophageal carcinoma--update.

Transhiatal esophagectomy with mobilization of the stomach to replace the esophagus has been used to provide palliation of dysphagia at the University of Michigan for more than 15 years. The subtotal esophageal resection is believed to be preferable to the transthoracic approach that has been considered the standard for this surgery. As experience with the technique has increased, complications have decreased. Most patients are discharged, able to swallow, by the 10th or 11th postoperative day. Survival in these patients is no worse than that reported after more traditional transthoracic esophagectomy, and the transhiatal route has reduced postoperative pulmonary complications and the incidence of mediastinitis from anastomotic leak, which is fatal in 50% of patients. In a phase II trial of preoperative combined radiation therapy and chemotherapy with cisplatin, vinblastine, and continuous-infusion 5-fluorouracil in 45 patients, survival after esophagectomy seemed considerably better than in our historical control subjects treated with transhiatal esophagectomy alone. The 3-year survival of the 43 patients was 46% compared with 23% of those who received only surgery. Considering only the 27% of those patients who had no cancer in their resected specimens, ie, the complete responders, the 5-year survival is 70%. A phase III trial is now accruing patients in an attempt to confirm these results.