What is the management of carcinoma of the cervical esophagus?

Management of Carcinoma of the Cervical Esophagus

For carcinoma of the cervical esophagus, definitive chemoradiotherapy should be the primary treatment of choice, with surgery reserved for salvage therapy in cases of treatment failure or selected cases requiring palliative intervention. 1, 2, 3

Diagnosis and Staging

• Endoscopic biopsy with histology according to WHO criteria is essential for diagnosis
• Complete staging workup includes:
  • Clinical examination
  • Blood counts and biochemistry (liver, renal function tests)
  • Endoscopy (including upper aerodigestive tract examination)
  • CT scan of chest and abdomen
  • Endoscopic ultrasound for T and N staging
  • PET-CT to identify otherwise undetected distant metastases 1, 4

Treatment Algorithm Based on Disease Stage

Early Disease (Tis-T1a N0)

• Endoscopic resection may be considered in specialized centers for very early lesions 1, 4
• Surgical resection may be considered for select patients with excellent performance status

Locally Advanced Disease (T1b-T4, N0-1)

• Primary treatment: Definitive chemoradiotherapy

  • Radiation dose: 60-66 Gy (EQD2 ≥66 Gy achieves local control of 94.7%) 5
  • Chemotherapy regimens:
    • High-dose cisplatin (80 mg/m² days 1 and 22) with 96-hour infusion of 5-FU (800 mg/m² days 2-5 and 23-26) OR
    • Low-dose cisplatin (20 mg/m² days 1-5 and 22-26) with similar 5-FU infusion 6
  • Radiation technique: IMRT or VMAT preferred to minimize toxicity 5
  • Include elective nodal irradiation for better regional control 5

• Salvage surgery considerations:

  • Reserved for persistent disease or local recurrence after chemoradiotherapy
  • Transcervical pharyngo-laryngo-cervico-esophagectomy with free jejunal flap reconstruction may be preferred over total pharyngolaryngeal esophagectomy with gastric pull-up to reduce morbidity 7

Metastatic Disease (M1)

• Palliative chemotherapy (cisplatin/5-FU based regimens)
• Endoscopic treatments for dysphagia (stenting)
• Single-dose brachytherapy for longer-term dysphagia relief 1
• Radiotherapy using small doses per fraction for symptomatic control 1

Treatment Outcomes and Prognosis

• Local complete response rate with definitive chemoradiotherapy: 91% 6
• Local control rate: 88% 6
• 3-year overall survival: 53.6% 5
• 3-year local regional failure-free survival: 57.9% 5
• Projected 5-year survival rate: 55% 6

Prognostic Factors

• Negative prognostic factors:
  • Advanced N stage
  • Hoarseness at presentation
  • Recurrent laryngeal nerve lymph node involvement
  • Inadequate radiation dose to GTV (< 66 Gy) 5

Monitoring and Follow-up

• Regular clinical examinations focusing on:
  • Dysphagia symptoms
  • Nutritional status
  • Sites of likely nodal relapse
• Follow-up intervals of 3-6 months
• Formal head and neck examination 12-18 months after initial treatment 1

Common Pitfalls and Complications

• Acute toxicities of chemoradiation:
  • Oral mucositis
  • Need for temporary feeding tube (nasogastric or gavage) in approximately 15% of patients 6
• Late complications:
  • Esophageal strictures (can be severe and potentially fatal)
  • Bilateral vocal cord palsy
  • Carotid artery blowout
  • Permanent hypothyroidism and hypoparathyroidism 2

Careful patient selection and treatment at high-volume centers with experienced multidisciplinary teams are critical for optimal outcomes in this challenging disease.