Journal of Surgical Oncology 46:107-109 (1991)
Comparison of Characteristics of Esophageal Squamous Cell Carcinoma Associated With Head and Neck Cancer and Those With Gastric Cancer HIROYUKI KUWANO, MD, MASARU MORITA, MD, SHIN-ICHI TSUTSUI, MD, YUlCHlRO KIDO, MD, MASAKI MORI, MD, AND KElZO SUGIMACHI, MD, FACS From the Department of Surgery I/, Faculty of Medicine, Kyushu University, Fukuoka, lapan
In ongoing reviews of 339 patients with surgically treated primary squamous cell carcinoma, there were 19 (5.6%) with concurrent gastric cancer and 11 (3.2%) with head and neck cancer. The incidences of intra-esophageal multiple occurrence of esophageal cancer are 27.3% and 26.3% in those with associated head and neck cancer and gastric cancer, respectively, and higher than 7.1% in those without such a concurrent cancer. There was no difference in the clinicopathological characteristics of those with concurrent head and neck and gastric cancers, except for the higher incidence of metachronous occurrence in the former. These findings suggest that, in cases of esophageal cancer associated with concurrent head and neck cancer and gastric cancer, intraesophageal multiplicity of the esophageal carcinoma is frequent and that preoperative serial evaluations is most important to design treatment and estimate the prognosis. KEYWORDS:multiple cancers, sequence of cancer occurrence, intra-esophageal multiplicity of carcinoma
INTRODUCTION Multiple independent occurrence of carcinoma in any organ has been thought to be a rare phenomenon. We reported that the incidence of multiplicity of esophageal carcinoma was 11.7 and 25.6% in those given and not given preoperative irradiation, respectively. A serial histologic investigation of the entire resected esophagus was made [ 11. On the other hand, esophageal cancer sometimes occurs concomitantly with head and neck and gastric carcinomas [2,3]. In the current study, we retrospectively investigated the characteristics of cases of esophageal squamous cell carcinoma associated with head and neck or gastric cancer, with special attention directed to the intra-esophageal multiplicity of esophageal carcinoma. PATIENTS AND METHODS Four hundred and twenty patients with primary esophageal carcinoma underwent esophageal resection in the Department of Surgery 11, Kyushu University, from 1965 to 1989. Excluding the 81 with tumors that were com0 1991 Wiley-Liss, Inc.
pletely destroyed by preoperative irradiation or that were cases of adenocarcinoma, 339 with primary squamous cell carcinoma of the esophagus were reviewed for the current report. In 39, there was a concurrent cancer in the esophagus and other organs. The incidence of associated organs in these concurrent cancers was stomach, 19; head and neck cancers, 11;lung, pancreas, sigmoid colon , and skin each two cases; and urinary bladder in one patient. In 19 and 11 cases of esophageal cancers associated with gastric cancers and head and neck cancers. cliniopathologic characteristics and intra-esophageal multiplicity of the esophageal carcinoma were given particular attention. Microscopic sections of the entire resected esophagus were prepared from a step-sectioned block 0.5 cm wide and were stained with hematoxylin and eosin (H&E). For the diagnosis of multiple primary carcinoma of the Accepted for publication October 17, 1990. Address reprint requests to Hiroyuki Kuwano, M.D., Department of Surgery 11, Faculty of Medicine, Kyushu University, 3-1- I , Maidashi, Higashi-ku, Fukuoka 812, Japan.
108
Kuwano et al.
esophagus, we made use of the following criteria; 1) each cancerous lesion showed definite malignant features histologically and was located individually with no continuity; and 2) second carcinomas accompanied the areas of intraepithelial carcinomas. We applied the latter to exclude intramural metastatic lesions, which frequently occur in patients with esophageal cancer. Thesignificance of difference was assessed using the chisquare test.
TABLE I. Location of the Cancers of Head and Neck Concurrent With Esonhawal Carcinoma
RESULTS Among 339 patients with primary squamous cell carcinoma of the esophagus, there were 11 and 19 with concurrent head and neck cancers and gastric cancers, respectively. Concerning the head and neck cancers, pharyngeal and laryngeal cancers occurred in each of three patients, cancers of the oral floor and gingiva in each of two, and tongue cancer in one. All head and neck cancers proved histologically to be squamous cell carcinomas (Table I). Nineteen gastric cancers were resected before or during the esophagectomy for a cancer, and the histological diagnosis was adenocarcinoma. Clinicopathologic characteristics of the esophageal carcinoma associated with head and neck cancers and gastric cancers are shown in Table 11. Average ages of the patients and the main location of the esophageal cancer with head and neck cancers and gastric cancers did not differ from those without such an association. However, the occurrence of concurrent esophageal and head and neck cancers or gastric cancers was prominent in male patients. Patients with concurrent esophageal and head and neck cancers were all men, and 17 of the 19 patients with esophageal and gastric cancers were also men. Incidences of multiple occurrence of carcinoma within the esophagus were 27.3% and 26.3% in those with head
and neck cancers and gastric cancers, respectively, and the incidence of the latter was significantly higher than the 7.1% in other cases. With regard to the sequence of occurrence of cancer of head and neck, stomach, and esophagus, 14 of 19 patients with gastric cancers were surgically treated at the same time as the treatment for an esophageal cancer; five had been resected more than 2 years before. On the other hand, only one of 11 patients with head and neck cancer was treated during the same hospital stay for the treatment of esophageal cancer (Fig. 1).
Location
No. of cases
Pharynx Larynx Oral floor Gingiva Tongue Total
3 3 2 2 1 11
DISCUSSION Concomitant cancer associated with esophageal carcinoma occurs most commonly in the stomach and head and neck regions [2,3]. Multicentric occurrence of carcinomas within the esophagus is also not rare, and we proposed that multicentric or field carcinogenesis would be one of the common processes and mode of the origin of the esophageal cancer [ 1,461. Although studies on the multiple occurrence of carcinomas within some organs [7,8] and the concomitant occurrence of cancers in multiple organs have been done [2,3,9], the relationship between multiple cancer occurrence within organs and in multi-organs has not been clearly demonstrated. The
TABLE 11. Clinicopathologic Characteristicsof 339 Patients With Esophageal Carcinoma (1965- 1989)T
Patients with esophageal plus concurrent head and neck cancer (n = 11) Mean age, (years) Sex Male Female Main location of esophageal cancer Upper Middle Lower Intra-esophageal multiple cancers (+)
(-1
65.4 1l(100) O(0)
Others (n = 309)
62.1
62.5
17(89.5) 2( 10.5)
26 l(84.5) 48(15.5)
4(2 1.1)
33( 10.7) 198(64.1) 78(25.2)
3(27.3) 5(45.5) 3(27.3)
1 l(57.9)
3(27.3)* 8(72.7)
5(26.3)** 14(73.7)
f Numbers in parentheses are percentages.
* P < 0.05. * * P < 0.01.
Patients with esophageal plus concurrent gastric cancer (n = 19)
4(21.1)
22( 7.1)*,** 287(92.9)
Esophageal Cancer With H & N and Gastric Cancers
head and neck cancer
gastric cancer
1I I 9
8
7
3
2
7
esophageal cancer
Fig. I .
109
8
9 1 0 (ws. 1
Sequence of the occurrence of cancers of head and neck, stomach, and esophagus
current study revealed the close relationship between multiplicity of the esophageal carcinoma and concurrent occurrence of carcinomas in organs adjacent to the esophagus, in the head and neck area, or in the stomach, and either a squamous cell carcinoma or an adenocarcinoma. Thus, aged men with esophageal cancer in particular should be closely examined for possible concomitant malignant lesions in the head and neck area and in the stomach. With regard to the sequence of the occurrence of cancers of the head and neck, stomach, and esophagus, most gastric cancers were detected and treated together with the esophageal tumor, while others were excised before the esophageal surgery. We also investigated cases of esophageal cancer occurring after gastrectomy and suggested that an esophageal cancer and a previous gastrectomy may be incidentally related [ 101. Thus, most gastric cancers were detected simultaneously with esophageal cancer and there was no case of occurrence of gastric cancer after esophageal surgery. This probably can be explained by the fact that the gastric tube was routinely used for esophageal substitution, and a preoperative serial examination of whole stomach was done [ 111. Therefore, preoperative routine examination of the head and neck area is also important and will enable the surgeon to treat such head and neck cancers simultaneously. As a close relationship exists between a concomitant head and neck or gastric cancer and an esophageal cancer, and the occurrence in elderly men is frequent,
preoperative serial examinations of the head, neck, and stomach should be made.
REFERENCES 1. Kuwano H, Ohno S, Matsuda H, Mori M, Sugimachi K: Serial
2.
3. 4.
5. 6.
7.
8. 9.
10. 11.
histologic evaluation of multiple primary squamous cell carcinomas of the esophagus. Cancer 61:1635-1638, 1988. Abemayor E, Moore DM, Hanson DG: Identification of synchronous esophageal tumors in patients with head and neck cancer. J Surg Oncol 38:94-96, 1988. Okudaira Y, Sugimachi K, Ueo H, Kai H, Kuwano N,Inokuchi K: Surgical treatment of concurrent cancer of the esophagus and stomach. J Surg Oncol 28:174176, 1985. Kuwano H, Ueo H, Sugimachi K, Inokichi K, Toyoshima S, Enjoji M: Glandular or mucus-secreting components in squamous cell carcinoma of the esophagus. Cancer 56514-518, 1985. Kuwano H, Matsuda H, Matsuoka H, Kai H, Okudaira k’, Sugimachi K: Intra-epithelial carcinoma concomitant with esophageal squamous cell carcinoma. Cancer 59:783-787, 1987. Kuwano H, Nagamatsu M, Ohno S, Matsuda H, Mori M, Sugimachi K: Coexistence of intraepithelial carcinoma and glandular differentiation in esophageal squamous cell carcinoma. Cancer 62:1568-1572, 1988. McCuirt WF, Matthews B, Koufmdn JA: Multiple simultaneous tumors in patients with head and neck cancer. Cancer 50:11951199, 1982. Shibuya H, Hisamitsu S, Shiroi S , Horiuchi J , Suzuki S: Multiple primary cancer risk in patients with squamous cell carcinoma of the oral cavity. Cancer 60:3083-3086, 1987. Nakayama K, Abo S: Concurrent cancer of the esophagus in Japan. Int Adv Surg Oncol 2:243-249, 1979. Kuwano H, Matsuda H, Nagamatsu M, Inoue T, Ohno S, Mori M, Sugimachi K: Occurrence of esophageal carcinoma after gastrectomy. J Surg Oncol 41:77-80, 1989. Sugimachi K, Yaita A, Ueo H, Natsuda Y, Inokuchi K: A safer and more reliable operative technique for esophageal reconstruction using a gastric tube. Am J Surg 140:471-474, 1980.
Comparison of Characteristics of Esophageal Squamous Cell Carcinoma Associated With Head and Neck Cancer and Those With Gastric Cancer HIROYUKI KUWANO, MD, MASARU MORITA, MD, SHIN-ICHI TSUTSUI, MD, YUlCHlRO KIDO, MD, MASAKI MORI, MD, AND KElZO SUGIMACHI, MD, FACS From the Department of Surgery I/, Faculty of Medicine, Kyushu University, Fukuoka, lapan
In ongoing reviews of 339 patients with surgically treated primary squamous cell carcinoma, there were 19 (5.6%) with concurrent gastric cancer and 11 (3.2%) with head and neck cancer. The incidences of intra-esophageal multiple occurrence of esophageal cancer are 27.3% and 26.3% in those with associated head and neck cancer and gastric cancer, respectively, and higher than 7.1% in those without such a concurrent cancer. There was no difference in the clinicopathological characteristics of those with concurrent head and neck and gastric cancers, except for the higher incidence of metachronous occurrence in the former. These findings suggest that, in cases of esophageal cancer associated with concurrent head and neck cancer and gastric cancer, intraesophageal multiplicity of the esophageal carcinoma is frequent and that preoperative serial evaluations is most important to design treatment and estimate the prognosis. KEYWORDS:multiple cancers, sequence of cancer occurrence, intra-esophageal multiplicity of carcinoma
INTRODUCTION Multiple independent occurrence of carcinoma in any organ has been thought to be a rare phenomenon. We reported that the incidence of multiplicity of esophageal carcinoma was 11.7 and 25.6% in those given and not given preoperative irradiation, respectively. A serial histologic investigation of the entire resected esophagus was made [ 11. On the other hand, esophageal cancer sometimes occurs concomitantly with head and neck and gastric carcinomas [2,3]. In the current study, we retrospectively investigated the characteristics of cases of esophageal squamous cell carcinoma associated with head and neck or gastric cancer, with special attention directed to the intra-esophageal multiplicity of esophageal carcinoma. PATIENTS AND METHODS Four hundred and twenty patients with primary esophageal carcinoma underwent esophageal resection in the Department of Surgery 11, Kyushu University, from 1965 to 1989. Excluding the 81 with tumors that were com0 1991 Wiley-Liss, Inc.
pletely destroyed by preoperative irradiation or that were cases of adenocarcinoma, 339 with primary squamous cell carcinoma of the esophagus were reviewed for the current report. In 39, there was a concurrent cancer in the esophagus and other organs. The incidence of associated organs in these concurrent cancers was stomach, 19; head and neck cancers, 11;lung, pancreas, sigmoid colon , and skin each two cases; and urinary bladder in one patient. In 19 and 11 cases of esophageal cancers associated with gastric cancers and head and neck cancers. cliniopathologic characteristics and intra-esophageal multiplicity of the esophageal carcinoma were given particular attention. Microscopic sections of the entire resected esophagus were prepared from a step-sectioned block 0.5 cm wide and were stained with hematoxylin and eosin (H&E). For the diagnosis of multiple primary carcinoma of the Accepted for publication October 17, 1990. Address reprint requests to Hiroyuki Kuwano, M.D., Department of Surgery 11, Faculty of Medicine, Kyushu University, 3-1- I , Maidashi, Higashi-ku, Fukuoka 812, Japan.
108
Kuwano et al.
esophagus, we made use of the following criteria; 1) each cancerous lesion showed definite malignant features histologically and was located individually with no continuity; and 2) second carcinomas accompanied the areas of intraepithelial carcinomas. We applied the latter to exclude intramural metastatic lesions, which frequently occur in patients with esophageal cancer. Thesignificance of difference was assessed using the chisquare test.
TABLE I. Location of the Cancers of Head and Neck Concurrent With Esonhawal Carcinoma
RESULTS Among 339 patients with primary squamous cell carcinoma of the esophagus, there were 11 and 19 with concurrent head and neck cancers and gastric cancers, respectively. Concerning the head and neck cancers, pharyngeal and laryngeal cancers occurred in each of three patients, cancers of the oral floor and gingiva in each of two, and tongue cancer in one. All head and neck cancers proved histologically to be squamous cell carcinomas (Table I). Nineteen gastric cancers were resected before or during the esophagectomy for a cancer, and the histological diagnosis was adenocarcinoma. Clinicopathologic characteristics of the esophageal carcinoma associated with head and neck cancers and gastric cancers are shown in Table 11. Average ages of the patients and the main location of the esophageal cancer with head and neck cancers and gastric cancers did not differ from those without such an association. However, the occurrence of concurrent esophageal and head and neck cancers or gastric cancers was prominent in male patients. Patients with concurrent esophageal and head and neck cancers were all men, and 17 of the 19 patients with esophageal and gastric cancers were also men. Incidences of multiple occurrence of carcinoma within the esophagus were 27.3% and 26.3% in those with head
and neck cancers and gastric cancers, respectively, and the incidence of the latter was significantly higher than the 7.1% in other cases. With regard to the sequence of occurrence of cancer of head and neck, stomach, and esophagus, 14 of 19 patients with gastric cancers were surgically treated at the same time as the treatment for an esophageal cancer; five had been resected more than 2 years before. On the other hand, only one of 11 patients with head and neck cancer was treated during the same hospital stay for the treatment of esophageal cancer (Fig. 1).
Location
No. of cases
Pharynx Larynx Oral floor Gingiva Tongue Total
3 3 2 2 1 11
DISCUSSION Concomitant cancer associated with esophageal carcinoma occurs most commonly in the stomach and head and neck regions [2,3]. Multicentric occurrence of carcinomas within the esophagus is also not rare, and we proposed that multicentric or field carcinogenesis would be one of the common processes and mode of the origin of the esophageal cancer [ 1,461. Although studies on the multiple occurrence of carcinomas within some organs [7,8] and the concomitant occurrence of cancers in multiple organs have been done [2,3,9], the relationship between multiple cancer occurrence within organs and in multi-organs has not been clearly demonstrated. The
TABLE 11. Clinicopathologic Characteristicsof 339 Patients With Esophageal Carcinoma (1965- 1989)T
Patients with esophageal plus concurrent head and neck cancer (n = 11) Mean age, (years) Sex Male Female Main location of esophageal cancer Upper Middle Lower Intra-esophageal multiple cancers (+)
(-1
65.4 1l(100) O(0)
Others (n = 309)
62.1
62.5
17(89.5) 2( 10.5)
26 l(84.5) 48(15.5)
4(2 1.1)
33( 10.7) 198(64.1) 78(25.2)
3(27.3) 5(45.5) 3(27.3)
1 l(57.9)
3(27.3)* 8(72.7)
5(26.3)** 14(73.7)
f Numbers in parentheses are percentages.
* P < 0.05. * * P < 0.01.
Patients with esophageal plus concurrent gastric cancer (n = 19)
4(21.1)
22( 7.1)*,** 287(92.9)
Esophageal Cancer With H & N and Gastric Cancers
head and neck cancer
gastric cancer
1I I 9
8
7
3
2
7
esophageal cancer
Fig. I .
109
8
9 1 0 (ws. 1
Sequence of the occurrence of cancers of head and neck, stomach, and esophagus
current study revealed the close relationship between multiplicity of the esophageal carcinoma and concurrent occurrence of carcinomas in organs adjacent to the esophagus, in the head and neck area, or in the stomach, and either a squamous cell carcinoma or an adenocarcinoma. Thus, aged men with esophageal cancer in particular should be closely examined for possible concomitant malignant lesions in the head and neck area and in the stomach. With regard to the sequence of the occurrence of cancers of the head and neck, stomach, and esophagus, most gastric cancers were detected and treated together with the esophageal tumor, while others were excised before the esophageal surgery. We also investigated cases of esophageal cancer occurring after gastrectomy and suggested that an esophageal cancer and a previous gastrectomy may be incidentally related [ 101. Thus, most gastric cancers were detected simultaneously with esophageal cancer and there was no case of occurrence of gastric cancer after esophageal surgery. This probably can be explained by the fact that the gastric tube was routinely used for esophageal substitution, and a preoperative serial examination of whole stomach was done [ 111. Therefore, preoperative routine examination of the head and neck area is also important and will enable the surgeon to treat such head and neck cancers simultaneously. As a close relationship exists between a concomitant head and neck or gastric cancer and an esophageal cancer, and the occurrence in elderly men is frequent,
preoperative serial examinations of the head, neck, and stomach should be made.
REFERENCES 1. Kuwano H, Ohno S, Matsuda H, Mori M, Sugimachi K: Serial
2.
3. 4.
5. 6.
7.
8. 9.
10. 11.
histologic evaluation of multiple primary squamous cell carcinomas of the esophagus. Cancer 61:1635-1638, 1988. Abemayor E, Moore DM, Hanson DG: Identification of synchronous esophageal tumors in patients with head and neck cancer. J Surg Oncol 38:94-96, 1988. Okudaira Y, Sugimachi K, Ueo H, Kai H, Kuwano N,Inokuchi K: Surgical treatment of concurrent cancer of the esophagus and stomach. J Surg Oncol 28:174176, 1985. Kuwano H, Ueo H, Sugimachi K, Inokichi K, Toyoshima S, Enjoji M: Glandular or mucus-secreting components in squamous cell carcinoma of the esophagus. Cancer 56514-518, 1985. Kuwano H, Matsuda H, Matsuoka H, Kai H, Okudaira k’, Sugimachi K: Intra-epithelial carcinoma concomitant with esophageal squamous cell carcinoma. Cancer 59:783-787, 1987. Kuwano H, Nagamatsu M, Ohno S, Matsuda H, Mori M, Sugimachi K: Coexistence of intraepithelial carcinoma and glandular differentiation in esophageal squamous cell carcinoma. Cancer 62:1568-1572, 1988. McCuirt WF, Matthews B, Koufmdn JA: Multiple simultaneous tumors in patients with head and neck cancer. Cancer 50:11951199, 1982. Shibuya H, Hisamitsu S, Shiroi S , Horiuchi J , Suzuki S: Multiple primary cancer risk in patients with squamous cell carcinoma of the oral cavity. Cancer 60:3083-3086, 1987. Nakayama K, Abo S: Concurrent cancer of the esophagus in Japan. Int Adv Surg Oncol 2:243-249, 1979. Kuwano H, Matsuda H, Nagamatsu M, Inoue T, Ohno S, Mori M, Sugimachi K: Occurrence of esophageal carcinoma after gastrectomy. J Surg Oncol 41:77-80, 1989. Sugimachi K, Yaita A, Ueo H, Natsuda Y, Inokuchi K: A safer and more reliable operative technique for esophageal reconstruction using a gastric tube. Am J Surg 140:471-474, 1980.
