食管癌NCCN临床教训2004.1版 医学解释网Esophageal Cancer NCCN? Practice Guidelines in Oncology ?v.1.2004 OverviewEpidemiology of Esophageal Carcinoma Upper gastrointestinal (GI) tract carcinomas (those originating in the esophagus， gastroesophageal junction， and stomach) constitute a major health problem around the world. It is estimated that approximately 36，960 new cases of upper GI carcinomas and 25，080 deaths will occur in the United States in 2004. During the past 15 years， there has been a dramatic shift in the location of upper GI tumors in the United States. Changes in histology as well as location of upper GI tumors have also been observed in some parts of Europe. In the Western Hemisphere countries， the most common site of esophageal carcinoma is in the lower third of the esophagus， where it often involves the gastroesophageal junction.(食谈癌在宇宙的发病情况及发生位置的改革)医学解释网Carcinoma of the esophagus is the ninth most common malignant disease around the world. It is endemic in many parts of the world，particularly in the developing nations. The incidence of esophageal carcinoma represents one of the widest variations， with a 100-fold difference between high- and low-incidence regions. An “esophageal cancer belt” extends from northeastern China to the Middle East， including the Caspian region of Iran， the Hunan Province in northern China， and many countries of the former Soviet Union. The Transkei area of South Africa also has a high incidence of esophageal carcinoma. In the United States， carcinoma of the esophagus is infrequent， constituting 1.5% of all malignancies and 7% of all GI cancers. Its incidence approaches 3.5 per 100，000 individuals per year. Approximately 14，250 new cases and 13，300 deaths are expected to occur in 2004.(食管癌发生的地域性)Although squamous cell carcinoma is most common in the endemic regions of the world， adenocarcinoma is most common in the world's nonendemic areas， such as North America and many western European countries. Squamous cell carcinoma occurs more frequently among men than women， and it is somewhat associated with alcohol and tobacco use. Patients with squamous cell carcinoma of the esophagus often have a history of prior head and neck carcinoma. Patients diagnosed with adenocarcinoma are predominantly white men (more so than those who develop squamous cell carcinoma)， and its association with alcohol or tobacco consumption is often not strong. Barrett's esophagus， gastroesophageal reflux， and hiatal hernia are often associated with adenocarcinoma of the esophagus.(食管癌的病理类型)[医学解释网整剪发布]Staging The modern staging of carcinoma of the esophagus is based on the tumor/node/metastasis (TNM) classification developed by the American Joint Committee on Cancer (see ). Clearly， patient outcomes depend on the initial stage of the cancer at diagnosis. Although surgical pathology yields the most accurate staging， the advent of better imaging techniques， including endoscopic ultrasonography， has improved preclinical staging. In western countries (such as North America and many western European countries)， where screening programs for early detection of esophageal cancer are not in use， the diagnosis is often made late in the course of the disease. At diagnosis， nearly 50% of patients have disease that extends beyond the locoregional confines of the primary. Fewer than 60% of patients with locoregional disease can undergo a curative resection. Nearly 70% to 80% of resected specimens harbor metastases in the regional lymph nodes. Thus， clinicians are often dealing with advanced-stage carcinoma in newly diagnosed patients.(分期，首诊时所处的分期)SurgeryThe incidence of carcinoma of the esophagus， particularly of adenocarcinoma of the distal esophagus， is increasing dramatically. As the incidence of patients with early-stage disease increases as a result of surveillance programs for columnar-lined epithelium， an increasing number of patients with esophageal cancer are expected to be candidates for resection.(可切除食管癌病例数加多)OutcomesOne of the major developments in the surgical therapy of carcinoma of the esophagus has been the marked improvement in surgical morbidity and mortality as a result of improvements in staging techniques， patient selection， and support systems. Surgical management of patients with esophageal cancer may include staging， resection with curative intent， and palliative techniques.The intent of surgery should be to achieve an R0 resection. Palliative resections should be avoided in patients with clearly unresectable or advanced disease who can be effectively palliated using nonsurgical modalities. The 5-year survival after an R0 resection is 15% to 20%， and the median survival after R0 resection is approximately 18 months; there is no difference is survival between groups treated with surgery alone or induction therapy followed by surgery.Long-term outcomes depend on the initial stage of the carcinoma at diagnosis. Stage I， II， and III disease are considered potentially resectable. Aggressive preoperative staging (including esophageal ultrasound， positron-emission tomography， and molecular biologic techniques ) may result in improved prognostic stratification， improved patient selection for surgical therapy91porn 下载， and improved overall survival. Selecting patients for surgery includes assessing their physiologic operability as well as extent of disease. Patients with advanced comorbidity91porn 下载， including severe cardiac and pulmonary disease91porn 下载， are not considered for resection but may benefit from noninvasive palliative interventions. However， most patients with early-stage disease will tolerate resection.Surgical ApproachesVarious surgical approaches may be used， depending on the size and location of the primary tumor and on the preferences of the surgeon. The optimal location of the anastomosis has been debated. The advantages of the cervical anastomosis include more extensive resection of the esophagus， the possibility of avoiding thoracotomy，less-severe symptoms of reflux， and less-severe complications related to anastomotic leak. Advantages of the thoracic anastomosis include a lower incidence of anastomotic leak and a lower stricture rate. Although some surgeons prefer the colon interposition， most surgeons use the stomach as the conduit to replace the esophagus after esophagogastrectomy. The use of the gastric conduit simplifies the procedure and is associated with equivalent patient satisfaction and fewer postoperative complications. Colon interposition is usually reserved for patients who have had previous gastric surgery or other procedures that have devascularized the stomach.There are several acceptable approaches for esophagogastrectomy.Ivor-Lewis esophagogastrectomy uses abdominal and right thoracic incisions， with upper thoracic esophagogastric anastomosis (at or above the azygos vein). Mobilization of the stomach for use as the conduit is performed， with dissection of the celiac and left gastric lymph nodes， division of the left gastric artery， and preservation of the gastroepiploic and right gastric arteries. This approach may be used for lesions at any thoracic location， but margins may be inadequate for tumors in the middle esophagus. Transhiatal esophagogastrectomy is performed using abdominal and left cervical incisions. The mobilization of the stomach for use as the conduit is performed as in the Ivor-Lewis esophagogastrectomy.This is completed via the abdominal incision， and the gastric conduit is drawn through the mediastinum and exteriorized in the cervical incision for the esophagogastric anastomosis. This approach may be used for lesions at any thoracic location; however， transhiatal dissection of large， middle esophageal tumors adjacent to the trachea is difficult and may be hazardous.Left thoracoabdominal esophagogastrectomy uses a contiguous abdominal and left thoracic incision， through the eighth intercostal space. Mobilization of the stomach for use as the conduit is performed as described previously， and esophagectomy is accomplished via the left thoracotomy. Esophagogastric anastomosis is performed in the left chest， usually just superior to the inferior pulmonary vein， although it may be performed higher if the conduit is tunneled under the aortic arch. This approach may be used for lesions in the distal esophagus.(术式)Radiation TherapySeveral historical series have reported results of using external beam radiation therapy (RT) alone. Most of these series included patients with unfavorable features， such as clinical T4 disease.Overall， the 5-year survival rate for patients treated with conventional doses of RT alone is 0% to 10%. Shi et al reported a 33% 5-year survival rate with the use of late-course accelerated fractionation to a total dose of 68.4 Gy. However， in the RT alone arm of the Radiation Therapy Oncology Group (RTOG) 85-01 trial， in which patients received 64 Gy at 2 Gy/d with conventional techniques， all patients died of disease by 3 years. Therefore， the panel recommends that RT alone should generally be reserved for palliation or for patients who are medically unable to receive chemotherapy. (单纯外放疗)Alternative radiation approaches， such as hypoxic cell sensitizers and hyperfractionation， have not resulted in a clear survival advantage. Experience with intraoperative radiation as an alternative to external-beam radiation is limited. Conformal and intensity-modulated RT are currently being investigated. In the adjuvant setting， randomized trials do not show a survival advantage for preoperative or postoperative RT alone. A meta-analysis from the Oesphageal Cancer Collaborative Group also showed no clear evidence of a survival advantage with preoperative radiation.(泛氧细胞，适形放疗在食管癌中专揽)Chemoradiotherapy The only randomized trial that was designed to deliver adequate doses of systemic chemotherapy with concurrent RT was the RTOG 85-01 trial reported by Herskovic et al and others. This Intergroup trial primarily included patients with squamous cell carcinoma. Patients received 4 cycles of 5-fluorouracil (5-FU) and cisplatin. Radiation therapy (50 Gy at 2 Gy/d) was given concurrent with day 1 of chemotherapy. The control arm was RT alone， albeit a higher dose (64 Gy) than in the combined modality therapy arm. Patients who were randomly assigned to receive combined modality therapy had a significant improvement in both median (14 versus 9 months) and 5-year survival (27% versus 0%). With a minimum follow-up of 5 years， the 8-year survival was 22%. The incidence of local failure as the first site of failure (defined as local persistence plus recurrence) was also lower in the combined modality arm (47% versus 65%).(放化疗运筹帷幄裸露更好疗效，惟有鳞癌入组)The INT 0123 trial was the follow-up trial to RTOG 85-01. In this trial， patients with either squamous cell carcinoma (85%) or adenocarcinoma (15%) who were selected for a nonsurgical approach were randomly assigned to a slightly modified RTOG 85- 01 combined modality regimen with 50.4 Gy versus the same chemotherapy with a higher dose of radiation (64.8 Gy). For the 218 eligible patients， there was no significant difference in median survival (13.0 versus 18.1 months)， 2-year survival (31% versus 40%)， and local/regional failure or local/regional persistence of disease (56% versus 52%) between the high-dose and standarddose RT arms. Recent trials have used more novel agents such as paclitaxel-based， docetaxel-based， or irinotecan-based chemotherapy. Four randomized trials comparing preoperative combined modality therapy with surgery alone in patients with clinically resectable disease show conflicting results. Therefore， although this approach is reasonable， it remains investigational.(高剂量放疗运筹帷幄化疗，有鳞癌也有腺癌入组)Brachytherapy(近距离放疗)Brachytherapy alone is a palliative modality and results in a local control rate of 25% to 35% and in a median survival of approximately 5 months. In the randomized trial from Sur and colleagues， there was no significant difference in local control or survival with high-dose-rate brachytherapy compared with external beam. In the RTOG 92-07 trial， 75 patients received the RTOG 85-01 combined modality regimen (5-FU/cisplatin/50 Gy) followed by an intraluminal boost. Local failure was 27%， and acute toxicity included 58% with grade 3， 26% with grade 4， and 8% with grade 5. The cumulative incidence of fistula was 18% per year， and the crude incidence was 14%. Therefore， the additional benefit of adding intraluminal brachytherapy to radiation or combined modality therapy， although reasonable， remains unclear.ChemotherapyChemotherapy can provide transient palliation for some patients with advanced locoregional carcinoma， but other approaches (including combined modality therapy) are more effective for this purpose. Chemotherapy alone has been investigated in the preoperative setting. The preliminary results of an intergroup trial (Intergroup 0113)， in which patients with potentially resectable carcinoma of the esophagus of both histologic types were randomly assigned to receive either preoperative chemotherapy with 5-FU plus cisplatin or surgery alone， did not demonstrate any survival benefit among the patients who received preoperative chemotherapy.The Medical Research Council (MRC) recently published their trial，which involved 802 patients with potentially resectable carcinoma of the esophagus. In this trial， patients were randomly assigned to receive 2 cycles of preoperative 5-FU (1000 mg/m per day by continuous infusion for 4 days) and cisplatin (80 mg/m on day 1) repeated every 21 days followed by surgery or surgery alone. However， this trial has several clinical methodology problems.Nearly 10% of patients received off-protocol preoperative radiotherapy， and patients accrued in China were excluded. At a short median follow-up time of 2 years， there was a 3.5-month survival time advantage (16.8 versus 13.3 months) for the group treated with preoperative chemotherapy. The median survival of the control group is less than expected. A longer follow-up would be necessary to understand whether this advantage in survival time would prevail. The panel does not recommend preoperative chemotherapy as standard of care. Thus， currently， preoperative chemotherapy cannot be recommended outside of a protocol in the treatment of locoregional carcinoma of the esophagus. Similarly，there is no standard postoperative systemic chemotherapy for patients who have undergone an R0 resection.(术后\术前化疗)The list of established chemotherapeutic drugs active against esophageal carcinoma is small. In the past 25 years， only 16 cytotoxic drugs were investigated systematically against metastatic esophageal carcinoma. The activity of nearly all these agents was established against squamous cell histology. Cisplatin has been considered one of the most active agents， with a single-agent response rate consistently in the range of 20% or greater. Older agents considered to be active include 5-FU， mitomycin， cisplatin， bleomycin， methotrexate， mitoguazone， doxorubicin， and vindesine. Newer agents that have shown activity include paclitaxel， docetaxel，vinorelbine， oxaliplatin with 5-FU， and lobaplatin.Combination chemotherapy for metastatic carcinoma of the esophagus continues to evolve. Compared with adenocarcinoma，squamous cell carcinoma appears to be more sensitive to chemotherapy， chemoradiation， or radiotherapy; however， there is no difference in the long-term outcome of patients with the two histologic types. The combination of 5-FU plus cisplatin is considered to be an acceptable therapy. It is the most investigated and most commonly used regimen for patients with carcinoma of the esophagus. Reported response rates to this combination vary between 20% and 50%. Paclitaxel combined with 5-FU and cisplatin has demonstrated activity in patients with squamous cell carcinoma and adenocarcinoma. In addition， the combination of irinotecan (CPT-11) and cisplatin appears to have activity， particularly against squamous cell carcinoma of the esophagus. Patients with esophageal cancer may benefit from noninvasive techniques that address obstruction， dysphagia， tracheoesophageal fistula， and GI bleeding. In patients with unresectable carcinoma or incurable carcinoma associated with dysphagia， the most realistic goal would be to provide symptomatic relief， which may improve nutritional status， the sensation of well-being， and overall quality of life.(化疗药物)Endoscopic PalliationCurrently available endoscopic palliative methods to overcome dysphagia include balloon dilatation or bougienage， thermocoagulation (laser)， injection of alcohol or chemotherapeutic agents， photodynamic therapy， intracavitary irradiation， and placement of a plastic or expandable metal prosthesis. The combination of photodynamic therapy (PDT) and the self-expanding stents provides the best palliation for most patients with obstruction and unresectable esophageal carcinoma. Patients with tracheoesophageal fistula are usually treated effectively with the placement of a silicone-covered self-expanding metal stent， obviating palliative esophageal exclusion and bypass in most patients. Placement of a gastrostomy or jejunostomy tube may help improve patients' nutritional status.(内镜下故息养息)WorkupTreatment GuidelinesNewly diagnosed patients should undergo a complete history， physical examination， and endoscopy of the entire upper GI tract. Histologic confirmation of carcinoma is required. Patients in whom the upper GI tract cannot be visualized should undergo a doublecontrast barium study of the upper GI tract. A complete blood count，multichannel serum chemistry analysis， coagulation studies， and computed tomographic (CT) scan of the chest and abdomen should also be performed. If the carcinoma is located at or above the carina， bronchoscopy (including biopsy of any abnormality and cytology of the washings) should be performed.At this point， if there is no evidence of metastatic disease，endoscopic ultrasonography (with FNA if indicated) is recommended. In addition， if the carcinoma is located at the gastroesophageal junction， laparoscopic staging of the peritoneal cavity is optional. Recently positron-emission tomography scans have been used in the evaluation of esophageal lesions， but the use of this modality is still considered optional pending further studies to more precisely define its value. Suspicions for metastatic disease should be confirmed by biopsy. This workup enables patients to be separated into two groups: (1) patients with apparent locoregional carcinoma (stages I to III)， and (2) those with obvious metastatic carcinoma (stage IV).Esophagogastric JunctionCancer of the esophagogastric junction has been characterized by Siewert and colleagues. If the tumor center or more than 66% of the tumor mass is located more than 1 cm above the anatomic gastroesophageal junction， then the tumor is classified as an adenocarcinoma of the distal esophagus， type I. If the tumor center or tumor mass is located within 1-cm oral and 2-cm distal to the anatomic gastroesophageal junction， this adenocarcinoma is classified as type II. If the tumor center or more than 66% of the tumor mass is located more than 2 cm below the anatomic gastroesophageal junction， these adenocarcinomas are classified as a court of tumors (adenocarcinoma of the gastroesophageal junction， type III).More recently， the classification has changed slightly. Patients whose tumors have a center that is 5-cm proximal or distal to the anatomic cardia are classified as having adenocarcinomas of the esophagogastric junction. These tumors include type I adenocarcinoma， which may infiltrate the esophagogastric junction from above; type II adenocarcinoma， which arises from the esophagogastric junction; and type III adenocarcinoma， or subcardial gastric carcinoma， which infiltrates up to the esophagogastric junction from below.Siewert and colleagues note that the description of these types of tumors is purely morphologic based on the anatomic location of the epicenter of the tumor or the location of the tumor mass. Various techniques used to make this determination can include barium esophagraphy， esophagoscopy， and CT. An individualized therapeutic approach may be preferred for specific patients and for specific tumor locations， based on thorough pretreatment staging. Therapeutic decisions may be refined by considering the location of the individual tumor and the specific requirements for local control.Additional Evaluation(术前查抄)For patients with apparent locoregional carcinoma， additional evaluations may be warranted to assess their medical condition; these evaluations are mandatory for patients with celiac-positive disease. These evaluations may include pulmonary function studies， cardiac testing， and nutritional assessment. For preoperative nutritional support， a nasogastric or jejunostomy tube should be considered; percutaneous endoscopic gastronomy (PEG) is not recommended. Moreover， evaluation of the colon by barium x-ray or colonoscopy may be warranted if colon interposition is planned as part of the surgical procedure. A superior mesenteric artery angiogram should be considered only in selected cases when colon interposition is planned. A PET scan is useful if available. Because the management of esophageal cancer requires the expertise of several disciplines---thoracic surgery， radiation oncology， medical oncology， nutritional and pulmonary support， and endoscopy---multidisciplinary evaluation is encouraged.Primary Therapy(首选养息，一线养息)Operable patients with a resectable (stages I-III or T1-T3， N0-1 or NX) carcinoma have two options (see ): esophagectomy or definitive chemoradiotherapy. The choice of surgical procedure depends on the preferences of the participating institution. However，surgery is recommended for patients whose carcinoma is below the level of the carina and for whom a procedure involving gastric reconstruction is preferred. Chemoradiotherapy should include 50 to 50.4 Gy of radiotherapy plus concurrent chemotherapy with 5-FU plus cisplatin. Chemoradiotherapy is the preferred modality for cervical esophageal carcinoma.After esophagectomy， patients with R0 resection and no nodal disease have three options (1) those with T1 should be observed，and no further therapy may be recommended in the absence of evident disease; (2) those with T2， N0 may be observed or selected patients can receive chemotherapy/RT; and (3) those with T3， N0 may receive chemotherapy/RT. Selected patients (limited to lower esophageal or gastroesphageal junction) with T2， NO are (1) higher risk patients with poorly differentiated histology， lymphovascular invasion， or neurovascular invasion or (2) young patients. Patients with R1 resections should be offered radiotherapy with 5-FU/cisplatin chemotherapy. Patients with R2 resections should be treated with chemoradiation or salvage therapy， depending on the extent of the disease. For patients found to have positive nodes after surgery， follow-up treatment is based on the location and histology of the lesion. Patients with adenocarcinoma of the distal esophagus or gastroesophageal junction should receive postoperative adjuvant chemotherapy and radiation therapy，whereas adenocarcinomas of the proximal- or mid-esophagus or any squamous carcinoma should just be observed.(可切除肿瘤的养息)In patients treated with definitive chemoradiotherapy放化疗， a CT scan is recommended as well as a follow-up upper GI tract endoscopy 4 to 6 weeks after the patient completes therapy. If a complete response(CR) can be documented， the patient may be observed or offered esophagectomy. Esophagectomy is preferred for patients with adenocarcinoma of the distal esophagus or gastroesophageal junction. Observation is recommended for patients with adenocarcinomas of the proximal- or mid-esophagus or any squamous carcinoma; however， esophagectomy is included in the guidelines as a category 2B recommendation for these patients. If there is evidence of persistent or recurrent local carcinoma，however， the patient can be offered esophagectomy or other methods of palliation.(术前扶助养息)Patients with unresectable (T4) carcinoma or those who do not choose to undergo surgery may be treated with 50 to 50.4 Gy of radiotherapy plus concurrent chemotherapy using 5-FU plus cisplatin， which is the preferred treatment. Best supportive care is a reasonable alternative in patients with inoperable tumors and is the recommended treatment if the patient cannot tolerate chemotherapy.(不行切除癌的养息)Follow-up(随访)All patients should be followed systematically (see ).Follow-up should include a complete history and physical examination every 4 months for 1 year， then every 6 months for 2 years， and annually thereafter. A complete blood count血老例， multichannel serum chemistry evaluation生化， and a chest radiograph胸片should be obtained as clinically indicated. Other investigations， such as endoscopy 内镜and other radiologic studies， should also be considered as clinically indicated临床发扬. In addition， some patients may require dilatation of an anastomotic吻合语气囊推广 or a chemoradiation-induced stricture.Salvage Therapy(晚期食管癌的"拯救"养息)Salvage therapy can range from aggressive intervention with curative intent 养息为蓄意介入养息in patients with locoregional relapse to therapy intended strictly for palliation 打消局促为蓄意故息养息in patients for whom cure is not a possibility. For patients with local relapse who receive no prior RT or chemotherapy， the preferred option is radiotherapy plus concurrent 5-FU--cisplatin chemotherapy with other alternatives， including endoscopic therapies. In selected patients with anastomotic recurrences吻合口复发， reresection can be considered. For patients who develop a resectable locoregional relapse after chemoradiotherapy， the clinician should determine whether the patient is medically fit for surgery (ie， operable)体质是否充许手术and if the relapse is technically resectable本事原因所致复发. If both of these criteria are met， surgery remains an option. If the patient has another relapse after surgery， the carcinoma should be considered incurable 不行调理and the patient should receive palliative therapy. Medically inoperable patients or those who develop an unresectable relapse after chemoradiotherapy may be offered brachytherapy， laser therapy激光切开松解， photodynamic therapy光能源疗法（PDT）， or any other components of best supportive care including esophageal dilatation (see ).For patients with metastatic carcinoma， only palliative care is appropriate. Whether to offer best supportive care alone or together with chemotherapy should be based on the patient's performance status(PS评分). Patients with a Karnofsky performance(卡氏评分)score of 60 or less or with a score of 3 or more on the Eastern Cooperative Group (ECOG) scale should be offered only best supportive care. Patients with better performance status may be offered best supportive care alone or with chemotherapy. If chemotherapy is selected for palliation， patients should be encouraged to enroll in available clinical trials. Outside of a clinical trial， a patient's chemotherapy may consist of a 5-FU--based， cisplatin-based， or taxane-based chemotherapy. Patients may be offered two sequential regimens.Best Supportive Care(养分复古养息)The constituents of best supportive care depend on the patient's symptoms. In the case of esophageal obstruction， the patient may be offered a stent placement食管内支架养息 ， laser surgery激光切开松解， photodynamic therapy光能源疗法（PDT）， radiotherapy放疗， or a combination of these methods， as appropriate. For patients requiring nutritional support， enteral feeding may be warranted. Pain control may be achieved with the use of radiotherapy plus pain medications. Similarly， surgery or radiotherapy and/or endoscopic therapy may be indicated in patients with brisk bleeding大出血from the carcinoma.Barrett's Esophagus(Barrett食管关联本色)Barrett's esophagus， the most important risk factor in the development of adenocarcinoma of the esophagus， is a metaplastic condition in which the normal squamous epithelium of the esophagus is replaced by columnar or glandular epithelium. The estimated prevalence of adenocarcinoma in columnar-lined esophagus ranges from 10% to 64% in the biomedical literature， which represents a 40-fold increase relative to the general population. Risk factors associated with development of malignancy include age， male sex， Caucasian race， specialized epithelial type， body mass index， and history of dysplasia.ManagementThe medical management is based on the symptomatic control of gastroesophageal reflux using histamine receptor antagonists or proton pump inhibitors. Endoscopic surveillance is performed to evaluate progression from metaplasia to low-grade dysplasia (LGD)， high-grade dysplasia (HGD)， or adenocarcinoma.Endoscopy is performed on patients with severe symptoms of gastroesophageal reflux， especially those with a family history of Barrett's esophagus or esophageal cancer. Once the diagnosis of metaplasia is established， routine endoscopic screening with 4- quadrant biopsy every 1 to 2 years is indicated. The screening interval is decreased to 6 to 12 months if LGD is present. For patients with metaplasia or LGD， control of acid reflux is achieved with histamine receptor antagonists or proton pump inhibitors (omeprazole， esomeprazole， lansoprazole， rabeprazole， or pantoprazole).If HGD is discovered during surveillance， pathologic confirmation by a second pathologist should be obtained. Among patients found to have HGD， cancer is actually present in approximately 50%. In a study of 15 patients with a preoperative diagnosis of HGD who underwent esophagogastrectomy， the final pathologic study demonstrated carcinoma-in-situ in three patients (20%) and invasive carcinoma in eight patients (53%). A meta-analysis of published results of 119 patients undergoing resection demonstrated an operative mortality of 2.6%， an incidence of invasive cancer of 47%， and a 5-year survival in patients with invasive carcinoma of 82%. Thus， a substantial percentage of patients with HGD already have invasive carcinoma at the time of diagnosis; surgical resection is the treatment of choice for these patients.Alternative strategies for patients with HGD include mucosal ablation or further surveillance every 3 months. Mucosal ablation can be achieved with argon beam coagulation， thermal laser ablation， or PDT. Of these methods of mucosal ablation， PDT is superior for achieving ablation of metaplastic and dysplastic epithelium as well as for obviating the need for further interventions. However， lifelong surveillance with deep biopsies is still required for patients with HGD who are treated with PDT. For patients who are at high risk for surgery or who refuse endoscopic mucosal ablation， continued surveillance every 3 months is an option if definitive therapy would be offered for patients who develop adenocarcinoma. However， approximately 50% of patients with documented HGD actually have occult adenocarcinoma.Summary(小结)Esophageal cancer is a major health hazard in many parts of the world. The incidence of adenocarcinoma is increasing in white men， particularly in the nonendemic areas， such as North America and many western European countries. Barrett's metaplasia， gastroesophageal reflux， hiatal hernia， and obesity are thought to play a role in these cases. In addition， the most common location of esophageal carcinoma has shifted to the lower third of the esophagus.Unfortunately， esophageal carcinoma is often diagnosed late; therefore， most therapeutic approaches are palliative. Advances have been made in staging procedures and in therapeutic approaches. The NCCN Esophageal Cancer Guidelines emphasize that palpable advances have been made in the treatment of locoregional esophageal carcinoma. Similarly， endoscopic palliation of esophageal carcinoma has improved substantially because of improving technology. A number of new chemotherapeutic agents are on the horizon including antireceptor agents， vaccines， gene therapy， and antiangiogenic agents. The panel expects numerous advances in the treatment of esophageal carcinoma in the future.。濑亚美莉全集