Carcinosarcoma of the oesophagus.

J. S. A;, a 74-year-old man, presented with a four-week history of dysphagia, anorexia, and loss of weight. He stated that until a month previously he had been quite well apart from occasional episodes over the past two years of 'indigestion' and belching, readily relieved by medicines. The belching after meals had recently increased and was later followed by vomiting immediately after eating. For two weeks he had been unable to eat meat or other solid foods and had lived on fluids, eggs, and pur&e foods. He was able accurately to localize the obstruction at the level of the lower sternum. Over the period of this disability he had lost 8 lb. (3-6 kg.) in weight. On examination the patient was thin and had lost a good deal of weight. He had a marked pectus excavatum. The pulse was irregular and the blood pressure 140/70 mm. Hg. Examination of the heart revealed occasional ectopic beats but no cardiac enlargement. There was a grade 1 systolic ejection murmur. A barium study showed the presence of a large filling defect (Fig. 1) measuring 7x3 cm. in the midoesophagus with appearances suggestive of a sarcoma. The mass appeared lobulated and the oesophageal contour was virtually intact. The stomach and duodenum were normal. A chest radiograph showed moderately emphysematous lung fields. There were degenerative changes throughout the spine. At oesophagoscopy a coarsely nodular growth, partially obstructing the lumen of the oesophagus, was seen at 28 cm. from the upper alveolar margin. The tumour had the appearance of an unripe blackberry. Biopsies were taken, and on histological examination the tumour was reported to be a leiomyosarcoma. Though the patient was 74 years of age, thin, and frail, with a degree of pectus excavatum, he had reasonable cardiopulmonary function for his age and satisfactory ventilatory capacity. Operation with a view to resection of the tumour was therefore advised and was performed on 22 November 1966. With the patient in a semi-oblique position, an upper midline laparotomy incision was made. No secondaries were detected in the liver, and no abdominal lymph node enlargement was demonstrated. A right thoracotomy was then performed through the bed of the resected fifth rib. A large tumour mass, distending the mid-third of the oesophagus, was present. The upper limit was at the level of the azygos arch, and the growth extended downwards for about 3 in. (7-6 cm.). The mass did not appear to transgress the muscle wall of the oesophagus. The whole of the oesophagus from just below the thoracic inlet to the hiatal orifice was mobilized. Attention was then redirected to the laparotomy and a pyloroplasty was performed after mobilizing the