What are the treatment options for esophageal cancer?

Treatment Options for Esophageal Cancer

The primary treatment for esophageal cancer depends on stage: surgery is the treatment of choice for early-stage disease, preoperative chemoradiation is recommended for locally advanced disease, and definitive chemoradiotherapy is preferred for cervical esophageal cancer, with palliative approaches for metastatic disease. 1

Diagnosis and Staging

Accurate staging is crucial for determining appropriate treatment:

• Diagnosis via endoscopic biopsy with histology classified per WHO criteria
• Complete staging workup includes:
  • Clinical examination
  • Blood tests
  • Endoscopy
  • CT scan of chest and abdomen
  • Endoscopic ultrasound (EUS) - most accurate for determining depth of tumor invasion and regional lymph node involvement 1, 2
  • PET-CT - particularly useful for detecting distant metastases 3, 2
  • Laparoscopy for locally advanced adenocarcinomas of the esophagogastric junction 1

Treatment Algorithm Based on Stage

Early-Stage Disease (Tis-T1a N0)

• Endoscopic resection is preferred for very early lesions in specialized centers
  • Equal cure rates with less invasiveness compared to surgery 1
  • Should be performed at high-volume centers with experienced multidisciplinary teams

Early-Stage Disease (T1-2 N0 M0)

• Surgery is the treatment of choice 1, 4
  • Transthoracic esophagectomy with two-field lymph node resection and gastric tube reconstruction is standard
  • Minimally invasive esophagectomy is a feasible alternative that may decrease postoperative pulmonary infections and improve quality of life 1

Locally Advanced Disease (T3 or N1)

• Preoperative (neoadjuvant) chemoradiation followed by surgery 1, 5, 4

  • Increases complete tumor resection rates and improves survival
  • Cisplatin/5-FU combined with radiotherapy is considered best for adenocarcinoma 1
  • Caution: May increase postoperative mortality rate

• Preoperative chemotherapy is an option specifically for adenocarcinomas of the lower esophagus and esophagogastric junction 1

Cervical Esophageal Cancer

• Definitive chemoradiotherapy is the primary treatment of choice 1
• Surgery reserved for salvage therapy in cases of treatment failure

Unresectable or Medically Inoperable Disease

• Concurrent chemoradiotherapy is the standard of care 5
• Chemoradiotherapy is superior to radiotherapy alone 1

Metastatic Disease

• Palliative approaches:
  • Chemotherapy
  • Endoscopic treatments for dysphagia
  • Single-dose brachytherapy for symptom relief 1

Important Considerations

• Treatment should be performed at high-volume centers with experienced multidisciplinary teams, particularly for minimally invasive approaches and endoscopic treatments 1

• PET-CT imaging is valuable not only for initial staging but also for:

  • Predicting pathologic response to therapy
  • Detecting occult distant metastases that would make surgical attempts futile 3
  • Monitoring response to neoadjuvant therapy 2

• For patients receiving multimodality therapy, careful reassessment after neoadjuvant treatment is essential to determine if surgery remains appropriate 5, 2

• Regular follow-up should focus 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