Sustained complete remission of metastatic oesophageal adenocarcinoma using long-term therapy with 5-fluorouracil

Patients with liver metastases of oesophageal cancer have a median survival of <1 year [1Go], while 5-year survival is anecdotal. We report a 7-year disease-free survival in a patient with histologically confirmed liver metastases of oesophageal adenocarcinoma treated with chemotherapy for 30 months.

A 70-year-old man was diagnosed in 1995 with a focally poorly differentiated adenocarcinoma of the lower oesophagus. History included myocardial infarction in 1991 and gastro-oesophageal reflux disease. World Health Organization performance status at the time of diagnosis was 1. Serum creatinine was elevated (155 µmol/l) due to nephroangiosclerosis. Carcinoembryonic antigen serum level was normal. Owing to a computed tomography finding of enlarged paraaortic/paratracheal lymph nodes, without evidence of systemic metastatic spread, neo-adjuvant chemotherapy with 5-fluorouracil (5-FU) as a continuous infusion (c.i.) for 5 days, combined with doxorubicin on day 1, in a 3-week schedule was started. Response to therapy was documented and the patient underwent radical oesophagectomy. Disease was classified as pT2pN0M0 according to tumour–node–metastasis classification (TNM Classification of Malignant Tumours, UICC, Sixth Edition 2002). Postoperative complications consisted of renal failure requiring transient dialysis, bilateral pneumonia and complex cardiac arrhythmia, which were all successfully managed. In the following year the patient underwent several endoscopic dilatations of benign anastomotic strictures without evidence of cancer. In March 1996, an abdominal ultrasound revealed two hepatic lesions, both in segment V, which were confirmed on biopsy to be metastases. Old age and cardiac and renal co-morbidities were the reasons for treatment choice: low dose 5-FU c.i. with folinic acid given 14 out of 28 days. In November 1996, liver imaging disclosed the disappearance of all liver lesions (Figure 1Go). Therapy was continued as 5-day 5-FU infusion every 4–6 weeks until November 1998. The patient is still alive in complete remission (CR), with excellent quality of life despite regular peritoneal dialysis recently introduced for a worsening of the renal failure. Chemotherapy may offer palliation and prolongation of survival in patients with advanced oesophageal cancer. Cisplatin in combination with 5-FU, taxanes or irinotecan yield objective response rates of 30–50% [2Go], but the impact of response on survival and on quality of life is unclear due to the lack of information from comparative trials of chemotherapy versus supportive care alone. On the other hand, CRs are rare, and the duration of any response is typically short. Despite the suboptimal chemotherapy administered, the patient achieved a sustained CR persisting 5 years beyond completion of treatment. A similar favourable course of oesophageal cancer has been described only anecdotically in subjects with metastatic Barrett's adenocarcinoma [3Go] or squamous cell carcinoma [4Go].



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Figure 1 Representative abdominal CT scan images showing the disappearance of liver metastases.

 
Treatment outcome and prognosis in the case of an oesophageal carcinoma depends on both patient and disease characteristics. In advanced disease, performance status, extent of disease and lactate dehydrogenase are independent prognostic factors [5Go]. The median survival for patients with none of these variables is estimated to be 12 months, compared with 4 months for those who have all the unfavourable characteristics. We consider this case as the illustration of a possible, albeit extremely rare, cure of metastatic oesophageal cancer with prolonged use of chemotherapy. The particular role of the drug or the schedule used can only be speculated.

P. Saletti1,*, M. Ghielmini1, S. Martinoli2 and A. Goldhirsch1

1 Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; 2 Department of Surgery, Ospedale Regionale di Lugano, sede Civico, Lugano, Switzerland

* Email: pcsaletti{at}bluewin.ch

References

1. Enzinger PC, Ilson DH, Kelsen DP. Chemotherapy in esophageal cancer. Semin Oncol 1999; 26 (Suppl 5): 12–20.

2. Enzinger PC, Mayer RJ. Esophageal cancer. N Engl J Med 2003; 349: 2241–2252.[Free Full Text]

3. Mason GR, Micetich K, Aranha GV. Long-term survival of a patient widespread metastases from Barrett's adenocarcinoma. Eur J Surg Oncol 2001; 27: 509–514.[CrossRef][ISI][Medline]

4. Sumi H, Ohtsu A, Boku N et al. A case of inoperable esophageal carcinoma with hepatic and nodal metastases which showed a long-term survival after chemoradiotherapy including nedaplatin. Jpn J Clin Oncol 2000; 30: 406–409.[Abstract/Free Full Text]

5. Polee MB, Hop WCJ, Kok TC et al. Prognostic factors for survival in patients with advanced oesophageal cancer treated with cisplatin-based combination chemotherapy. Br J Cancer 2003; 89: 2045–2050.[CrossRef][ISI][Medline]





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