Three decades of treatment of esophageal squamous carcinoma at the Massachusetts General Hospital

Seven hundred one patients with squamous cell carcinoma of the esophagus who were treated between 1950 and 1979 were retrospectively studied. The percentage of male patients decreased over the three decades (80% to 69%); the proportion of cigarette and alcohol abusers doubled. The esophageal carcinoma was located as follows: upper third, 24.7%; middle third, 52.8%, and lower third, 22.5%. There was disparity in clinical, surgical, and pathologic staging. More than two thirds of the patients thought to have stage II lesions proved to have stage III lesions on pathologic examination; nearly one half of patients thought to have stage II disease intraoperatively were found to have pathologic stage III lesions. This 'upgrading' of stage was chiefly a result of histologic recognition of nodal metastasis or extension of carcinoma into surrounding tissues. Operation was performed in 411 cases (58.6%) and resection was performed in 261 (37.2% overall). The postoperative death rate after resection fell from 30.5% in the 1950s to 10.4% in the 1970s, with respiratory complications the predominant cause of death. Analyses were based on treatment directed at the carcinoma itself; radiotherapy, 340 cases (48.5%); resection, 176 cases (25.1%); resection plus radiotherapy, 85 cases (12.1%); no definitive treatment, 100 cases (14.3%). Overall survival for the 701 patients was 13% at 2 years and 6% at 5 years (mean survival, 16.4 months); this did not differ by decade. Survival clearly differed by treatment (p = 0.001); resection plus radiotherapy provided the best survival (35% at 2 years; 20% at 5 years; mean of 32.5 months) followed by resection (18% at 2 years; 7% at 5 years; mean of 17.5 months), radiotherapy (9% at 2 years; 3% at 5 years; mean of 12.7 months), and no treatment (0% at 2 years; 0% at 5 years; mean of 2.5 months). Survival in patients who did not have resection did not differ by decade but survival in patients with resections improved in the last two decades. Patients with pathologic stage II lesions had greatly improved survival (54% at 2 years; 25% at 5 years; mean of 42.7 months) compared with patients with stage III disease (12% at 2 years; 6% at 5 years; (mean of 15.1 months) (p = 0.001).