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J Thorac Cardiovasc Surg 1994;108:512-516
© 1994 Mosby, Inc.
GENERAL THORACIC SURGERY |
Beijing, People's Republic of China
From the Department of Cardiothoracic Surgery, First Hospital of Beijing Medical University, Beijing, People's Republic of China.
Received for publication Feb. 5, 1993. Accepted for publication May 2, 1994. Address for reprints: Hongyi Chen, MD, Department of Cardiothoracic Surgery, First Hospital, Beijing Medical University, No. 8 Xishiku St., Beijing 100034, People's Republic of China.
Abstract
The clinicopathologic features of carcinomas of the esophagus and the cardia in young patients were reviewed in a study of 1302 consecutively treated patients. The patients were divided into two groups, with group I aged under 40 years and group II over 40 years. There were no significant differences between the two groups with regard to sex ratio, duration of the principal symptoms, and 5-year and 10-year survivals. The main clinicopathologic difference between the young patients and the older ones was that the carcinomas in young patients were more likely to invade the surrounding tissues. Local lymph node metastases and microscopic residual tumor at the line of resection were also more prevalent in the young patients, but not to a statistically significant degree. These findings suggested that the clinical and pathologic features of carcinomas of the esophagus and the cardia in young patients were not significantly different from those in older patients. (J THORACCARDIOVASCSURG1994;108:512-6)
Carcinomas of the esophagus and the cardia occur mainly in the fifth to seventh decades of life. These diseases are rare in patients aged less than 40 years. There are reports of clinicopathologic differences in gastric and colorectal carcinomas between young and elderly patients. 
1-3 However, the clinicopathologic features of carcinomas of the esophagus and the cardia in young patients are still unsettled in comparison with features in older patients. 4-6 In this report, a retrospective and comparative study is made of 59 young patients, younger than 40 years of age, from among 1302 consecutively treated patients with carcinomas of the esophagus and the cardia.
PATIENTS AND METHODS
Clinical data.
From 1954 to 1989, a total of 1302 Chinese patients with carcinomas of the esophagus and the cardia who were admitted to our hospital were divided into two groups according to their ages: group I, 40 years old or younger; group II, more than 40 years old.
Among the 59 patients in group I (4.5% of the total), 41 had carcinoma of the esophagus and 18, carcinoma of the cardia. The average age was 36.2 ± 0.5 years, with the youngest aged 19 years. The main symptom was dysphagia in all but two, who initially had severe chest pain. One patient had had chemical burning of the esophagus when he was a child and was cured medically, but dysphagia appeared again after 28 asymptomatic years and the postoperative pathology report revealed carcinoma of the esophagus.
A comparison of the clinical data between the two groups is shown in Table I.
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The operative approach was mainly through a left thoracotomy for esophageal carcinoma. The tumors were removed with or without a portion of the proximal stomach. Continuity of the gastrointestinal tract was restored manually by primary esophagogastrostomy. The anastomosis was done at the level of the neck in three patients, thoracic dome in one, supraaortic level in 28, and infraaortic level in two. Postoperative complications occurred in three patients; these included localized empyema, severe pulmonary infection, and anastomotic leakage. Two of the three patients with postoperative complications died within the first postoperative month. The operative mortality was 5.6% (2/36).
Of the 18 young patients with carcinoma of the cardia, 17 underwent esophagogastrectomy with infraaortic esophagogastrostomy and two had simultaneous splenectomy and partial pancreatectomy owing to the tumor's invasion of the spleen and the tail of the pancreas. One patient received a total gastrectomy with esophagojejunostomy. Two patients with toxic shock and incarcerated diaphragmatic hernia, respectively, died within 10 days after their operations. Both operative morbidity and operative mortality were 11.1% (2/18). Other clinical data are shown in 
Table I.
Pathology.
The excised samples were all sent to the department of pathology for macroscopic and microscopic evaluations.
Postoperative follow-up.
The follow-up was conducted mainly by correspondence and visits to the outpatient department. The longest duration of follow-up lasted 28 years. Postoperative follow-up was maintained in 84.4% of patients with carcinoma of the esophagus and 93.3% of those with carcinoma of the cardia in group I.
Statistical analysis.
Statistical analysis of discrete variables was done by the 
2 test. Survival data were generated by a life-table method and compared by the log-rank test. The difference is considered of significance at a p value less than 0.05.
RESULTS
Male preponderance was evident in both groups. There were no differences in general data (see Table I). Surgical resection remained the mainstay of the treatment of patients with carcinomas of the esophagus and the cardia. Radiotherapy and chemotherapy were the chief adjuvant procedures. In group I, 11 patients with esophageal carcinoma received preoperative or postoperative radiotherapy, or both; three patients with carcinoma of the cardia were given postoperative chemotherapy. The resectability of the two sorts of carcinomas in group I was higher than that in group II, but the differences were of no significance. If the data for the two types of carcinoma in each group were combined, the resectability differed significantly between the two groups (see Table I). Differences in operative mortality between the two groups did not reach statistical significance.
The postoperative pathologic results in group I revealed that carcinomas of the esophagus were all squamous cell carcinoma and carcinomas of the cardia were all adenocarcinoma. Early stages of carcinoma were rare in both groups; in most patients, the tumors had penetrated the whole thickness of the wall of the esophagus or the cardia. Infiltration of the surrounding tissue by the tumors was far more prevalent in group I than in group II. Local lymph node metastasis was also more common in group I, but the difference was not statistically significant (Table II). Residual microscopic disease at the end of the lines of resection was 1
times more common in group I than in group II; even so, the difference was of no statistical significance (Table II).
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Carcinomas of the esophagus and the cardia occur mainly in patients older than 50 years of age and are uncommon in young patients. The prevalence of the diseases in persons younger than 40 years of age ranges from 2.0% to 7.5%. 4,6-8 Of patients admitted from 1953 to 1973 to the First and the Second Hospitals of Beijing Medical University, those younger than 40 years of age accounted for 6.6% of all patients with carcinomas of the esophagus and the cardia (Fig. 3).
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9 suggested that sex, age, and duration of the primary symptom did not have a notable impact on the postoperative long-term survivals for patients with carcinomas of the esophagus and the cardia. Shao and colleagues, 5 however, found that age and duration of the primary symptom were independent prognostic indicators, closely associated with the postoperative long-term survival. They thought that carcinomas in young patients less than 40 years old grew more quickly, with a lower resectibility rate and a lower long-term survival than those of patients who were more than 60 years old. In 1990, Mori and coworkers 4 reported that esophageal carcinoma in patients less than 50 years old appeared to behave biologically like the same carcinoma in older patients. 4
Different age limits were used to divide the subjects in the aforementioned three trials, and this difference may have affected the final results of the studies. In Mori's report, 4 patients aged from 45 to 49 years comprised 67.8% of all who were defined as young; they may be too old to be regarded as young. Many researchers on tumors of other sites in the digestive tract defined the young patients as those aged under 40 or even younger. 1-3
In this report, the clinicopathologic features of carcinomas of the esophagus and the cardia in young patients aged under 40 years were reviewed in a study of 1302 consecutively treated patients. There were no differences in preoperative mean duration of the primary symptom and sex ratio between the two groups (see Table I). Postoperative pathologic results indicated that carcinomas in early stages were rare in both groups. More infiltration of surrounding tissue by tumors was found in group I patients than in group II patients. The occurrence of local lymph node metastases was not significantly different between the groups. Although some differences between the two groups reached statistical significance, postoperative pathologic results suggested that the pattern of the cancer's development in young patients parallelled its development in older ones. The high resectability rate with resultant high frequency of residual tumor at the resecting line also indicated the same surgical process among the young and older patients (Table II).
Five-year and 10-year postresection survivals of young patients were a little lower than those of older patients (Figs. 1 and 2), but log-rank tests showed that the differences were of no significance. To exclude the effects of sex, site of the tumor, pathologic TMN stages (according to the International Union Against Cancer [UICC] TMN classification), operative procedures, microscopic residual disease at the resection line, and adjuvant therapies on statistical analysis, we matched the patients with esophageal carcinoma in the two groups according to aforementioned conditions in a ratio of 1:3 (one young patient in group I to three older ones in group II) to perform the matched log-rank test. The result disclosed that there was no difference at all (Fig. 4).
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Acknowledgments
We express our appreciation to Ke-chun Sun, MD, and Feng Gao, BS, for their advice on statistics.
References
This article has been cited by other articles:
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  J.S. Rahamim, G.J. Murphy, Y. Awan, and M. Junemann-Ramirez The effect of age on the outcome of surgical treatment for carcinoma of the oesophagus and gastric cardia Eur. J. Cardiothorac. Surg., May 1, 2003; 23(5): 805 - 810. [Abstract] [Full Text] [PDF]
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 T. Nozoe, H. Saeki, T. Ohga, and K. Sugimachi Clinicopathologic characteristics of esophageal squamous cell carcinoma in younger patients Ann. Thorac. Surg., December 1, 2001; 72(6): 1914 - 1917. [Abstract] [Full Text] [PDF]
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S. Kinugasa, M. Tachibana, H. Yoshimura, D. K. Dhar, M. Shibakita, S. Ohno, H. Kubota, R. Masunaga, and N. Nagasue Esophageal resection in elderly esophageal carcinoma patients: improvement in postoperative complications Ann. Thorac. Surg., February 1, 2001; 71(2): 414 - 418. [Abstract] [Full Text] [PDF]
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