Treatment of esophageal cancer in inoperable elderly patients: our experience

The esophagus carcinoma has an incidence rate of 3–4 new cases per 100,000 inhabitants, per year, with a male/female ratio of 3:1 and with a low incidence between the VI–VII decade of life. In Italy, the incidence rate equals 2,000 new cases/year with a mortality rate of 3–5/100,000 inhabitants.


Introduction
The esophagus carcinoma has an incidence rate of 3-4 new cases per 100,000 inhabitants, per year, with a male/ female ratio of 3:1 and with a low incidence between the VI-VII decade of life. In Italy, the incidence rate equals 2,000 new cases/year with a mortality rate of 3-5/100,000 inhabitants.

Patients and methods
During the 1997-2007 decade, 57 cases of esophageal neoplasm were observed, of which 15 patients whose age range was 70-85 years, 11 males and 4 females, all presented with associated cardiovascular, respiratory and metabolic pathologies that would not allow the possibility of surgical approach. Patients enrolled in the current study contain in their clinical history several risk factors, and more precisely: Barrett's esophagus 2, Achalasia 3, Reflux esophagitis 5. Two out of 15 patients were alcoholdependent, whereas 11/15 were heavy smokers. All patients presented serious nutritional deficits. Diagnosis was made after symptoms of dysphagia manifested, after having undergone an endoscopic examination and biopsy. Clinical staging provided for the ultrasound examination and thoracic-abdominal CT. The neoplasias were located 12 in the cardiac region, 1 in the medio-thoracic region, 2 in the cervical tract. There were 5 carcinomas in situ, 4 infiltrating adenocarcinomas, 6 squamous cell carcinomas of which 3 stenosed, 2 ulcerated, 1 vegetative. Hepatic metastasis was present in 8 out of the 15 cases, lymphonodal and mediastinic in 2 cases. An endoscopic mucosectomy was performed in the 5 patients affected by carcinomas in situ. In the 3 patients affected with stenosed squamous cell carcinomas, a series of dilations and prosthetic nitinol stent positioning (Boston Scientifics) were undertaken in order to restore the passage as much as possible. The four infiltrating and metastatic adenocarcinomas were treated with chemotherapy cycles. A case of a vegetative tumor with hepatic metastasis was treated with Bicap use (monopolar electrode), with thermal destruction of the neoplastic tissue, and followed by a series of treatment cycles undertaken to eradicate it. The remaining two ulcerated cases were treated with Argon plasma coagulator.

Results
In five years, four out of five patients afflicted by carcinoma in situ treated with endoscopic mucosectomy were free from the ailment and did not present morbidity associated with the treatment undertaken, only one of them passed away due to a cardiovascular cause. Patients who underwent pneumatic dilatation and prosthetic placement obtained an excellent control of the dysphagic symptoms, especially in the first months after the prosthetic placement, with a considerable improvement in quality of life, but their survival rate did not surpass 18 months. The patients guided through chemotherapy cycles, while considering their general condition, of comorbidity and age, have had a considerable decrease in QL without obtaining noticeable improvements in the survival rate. Patients treated with Argon plasma coagula-from XXI Annual Meeting of The Italian Society of Geriatric Surgery Terni, Italy. 4-6 December 2008 tor (APC) and with Bicap have had a fast progression of the illness, a decrease in QL, and passed away in six months due to serious hemorrhagic complications.

Conclusion
In the treatment of esophageal cancer, when diagnosed after 70 years of age, it becomes indispensable to keep in mind, beyond the size of the tumor and diffusion of the ailment, the anagraphic age of the patient, the comorbidity presence, which renders a "radical" therapy disproportionate. It should be outlined the principle that a good palliation is more useful for patients of treatments which carry heavy risk, tending to radical surgeries of dubious use. The esophageal prosthetic placement seems to be the treatment of choice in inoperable stenosed carcinomas with the aim of restoring the passage and/or improving the dysphagia.
The endoscopic mucosectomy in agreement with literature data instead obtained indications in the inoperable carcinomas in situ. This low invasion and reliable method, from an oncologic point of view, allows for the complete remove of the mucous section of the lesion up to the lamina, and thanks to the use of image magnification techniques and the use of the Narrow Band Imaging, it is now more precise and safe. The mucosectomy contains risks comparable to a polypectomy and in regards to other methods boasts the advantage of quick execution and of offering a radical surgery that would not be otherwise achievable. Treatments with Argon plasma and with Bicap are considered to be entirely palliative, compulsory options in extremely advanced clinical cases and for severely malnourished patients. The chemo and radiotherapy are often impractical and when it's possible to follow the treatment, the limits placed on age and comorbidity present, drastically reduce their efficacy. Nevertheless, it continues to be imperative to improve the quality of life in inoperable geriatric patients.