Therapeutic Option in Patients over 60 Years with Esophageal and Esocardial Cancer

Background: Treatment of esophageal and esocardial cancer in patients over 60 years involves a particular management. Considering the comorbidities specifi c to this category of patients, recent data from the literature indicate an increased incidence of mortality and morbidity following therapy. Material and method: We retrospectively studied a group of 55 patients admitted to the Surgical Clinic I of the County Emergency Clinical Hospital Tîrgu Mureș, in the January 1st, 2007 – December 31st, 2011 period, diagnosed with esophageal and esocardial cancer. Patients were divided into two groups: group I under the age of 60 years, and group II over this age. Inclusion criteria were age, diagnosis (tumor location), and we followed a series of parameters: demographics, type of surgery, the biological profi le of patients, immediate postoperative morbidity and mortality. Results: No statistically signifi cant differences were observed in terms of demographics: gender (p = 0.78), area of origin (p = 0.69). The number of hospitalization days (p = 0.20) was infl uenced by the type of surgery, as well as preand postoperative comorbidities. Immediate postoperative mortality was 16.56%, the differences between the two groups was not statistically signifi cant (p = 0.58). Parameters with statistical signifi cance were found to be: age (p <0.0001), tumor location, type of surgery (p = 0.0031) and radical versus palliative surgery (p = 0.03). Conclusions: Therapeutic attitude in patients over 60 years should be correlated with specifi c particularities to this category. Selection of patients for surgery and type of surgery is dictated by the patient's condition and quantifi ed by anesthesia and surgery team.


Introduction
Th e increasing prevalence of esophageal and esocardial cancer represents a major health problem worldwide [1,2].Given the higher incidence of esophageal cancer in the 7 th and 8 th decade of life, the treatment of elderly patients involves a particular management due to age and associated comorbidities specifi c to this category of patients [2,3,4].
Ellis FH Jr et al. do not consider age a limiting factor in the aggressive management of elderly patients (aged over 70 years) [5].Fogh et al. report no signifi cant differences in terms of mortality and morbidity in elderly patients [6].Moreover, Dhungel et al. considered that advanced age, along with other signifi cant comorbidities (diabetes, stroke, peripheral vascular pathology), is a predictor of morbidity and mortality post-esophagectomy [7].Wright et al. studied morbidity and mortality following esophagectomy on a lot of 2315 patients operated for esophageal cancer, and identifi ed age (75 vs. 55 years), along with other comorbidities (diabetes mellitus, hypertension, smoking, coronary artery disease, etc.), as a predictor [8].In contrast, Ruola A et al. suggest that age itself should not be an exclusion criterion for esophagectomy [9].
Th erapeutic options for esophageal and esocardial cancer have changed in the last 10 years [10].Th e identifi cation of risk factors, the role of surgery in the multimodal treatment of this disease, as well as the proper selection of patients [11] continue to represent challenges in choosing the proper therapeutic strategy, correlating the risk-benefi t of each individual.
Th e objectives of our study were to evaluate the surgical options, the characteristics of immediate postoperative morbidity and mortality and the histology patterns of a group of patients diagnosed with esophageal and/or esocardial cancer.

Methods
We ran a retrospective observational study on a sample of 55 patients, hospitalized in the Surgery Clinic I of the County Emergency Clinical Hospital Tîrgu Mureș, between January 1 Statistical analysis was performed using MedCalc Software (Version 12.3.0bvba, Mariakerke, Belgium).Student's t test was used to assess the diff erences in continuous variables (expressed as mean ± SD) and Mann Whitney test for nonparametric variables (expressed as median and range) while the  2 test was used for category variables (expressed as no (%).We interpreted all the tests we have performed to the threshold of signifi cance p = 0.05 and statistical signifi cance was considered for p-values less than the threshold value of signifi cance.

Results
On the studied groups, no statistically signifi cant diff erences were observed regarding sex.Males were predominantly aff ected (86.86% and 84.38%) (Table I).Overall mortality was 16.56% without obvious diff erence between the two groups (Table I).Th ere was no diff erence between the mean values of BMI (p = 0.2).Th ere was no evidence of signifi cant diff erence in the area of origin, with rural area of origin being predominant (78.26% and 56.25%).
Regarding the number of days of hospitalization and number of days in the ICU, the diff erences were not statistically signifi cant in the studied groups, although the group over 60 years the number of days of hospitalization in the ICU was slightly higher.Th e onset of symptoms, between 8-12 months, was characteristic of both groups, as well as the presence of dysphagia as a dominant symptom.Both major comorbidities (diabetes mellitus, history of stroke, heart disease, lung disease) and postoperative morbidity (suppurations the wound, respiratory problems, anastomosis fi stula, diffi culty in resuming alimentation) presented statistically signifi cant diff erences in the studied groups (Table I).
In the group over 60 years the tumor was predominantly located esocardially and in the middle third of the esophagus (56.25% and 25%, respectively), compared to the group under 60 years where the predominant location was in the lower third (30.43%), the diff erence being statistically signifi cant (p = 0.0031) (Figure 1).
In the group over 60 years, palliative interventions dominated the therapeutic intent, there was a statistically signifi cant diff erence regarding surgical management of the two groups (Table II).
Regarding the histological characteristics of the tumors and T and N classifi cation, there were no statistically signifi cant diff erences noted between the two groups (Table III).IV).
Our results suggest that tumor characteristics (histologic type) do not infl uence the therapeutic decision, radical intent being primordial in the case of patients with esophageal cancer.
We found that the tumors were located more commonly in the distal third of the esophagus in group II, while in group I they were located predominantly in the middle third (81.25% and 52.17%, p = 0.0031), similarly to the fi ndings of Dreilich M et al. [13].Full evaluation of preoperative comorbidities is essential in choosing the type of surgery, considering the anesthetic risk correlated with postoperative evolution [14].
Comorbidities (cardio-pulmonary, diabetes, etc.) were more common in group II, which infl uence the type of intervention, representing contraindication to extensive surgery in the chest and performing a minimum surgical act (jejunostomy, gastrostomy).
Postoperative evolution of patients is infl uenced to a greater extent by the existence of comorbidities, while immediate postoperative mortality is not higher following radical surgery, compared with palliative surgery.

Conclusions
Our results suggest that age, as a singular criterion, should not be an impediment in the selection of patients for a radical intervention.
Surgical interventions for esophageal cancer and esocardial are the prerogative of experienced surgical and anesthetic teams, preoperative and postoperative care is often as important as the type of surgical procedure chosen.

Table II .
Type of surgery

Table III .
Tumor characteristics of esophageal and esocardial cancer

Table IV .
Type of surgery: radical vs. palliative