What are the treatment options for oesophagus (esophageal) cancer?

Treatment Options for Oesophageal Cancer

The treatment of oesophageal cancer should be based on tumor stage, with surgery recommended as the standard treatment for early-stage disease (stages I and II), while locally advanced disease may benefit from multimodal approaches including chemoradiotherapy and surgery. 1

Diagnostic Workup

• Diagnosis should be made from endoscopic biopsy with histopathological classification according to World Health Organization criteria 1
• Staging should include clinical examination, blood tests (including liver, pulmonary, and renal function), endoscopy, and CT scan of chest and abdomen 1
• For surgical candidates, endoscopic ultrasound and PET-CT should be added to evaluate tumor depth and nodal involvement 1
• Laparoscopy can be helpful in locally advanced (T3/T4) adenocarcinomas of the oesophago-gastric junction to rule out peritoneal metastases 1

Treatment Options by Stage

Early Disease (Tis-T2, N0)

• Surgery is the treatment of choice for early cancer (Tis-T1a N0) 1
• Endoscopic resection is a treatment option for selected patients with early disease, as similar cure rates have been reported in specialized centers 1
• For localized disease without suspected lymph node involvement (T1-2 N0M0), surgery is the standard treatment 1

Limited Disease with Lymph Node Involvement (T1-2, N1-3)

• For localized disease with suspected lymph node involvement (T1-2 N1-3M0), preoperative therapy is recommended, particularly for adenocarcinoma 1
• The standard surgical technique is subtotal transthoracic oesophagectomy with concurrent nodal clearance and gastroplasty if possible 1

Locally Advanced Disease (T3-T4, N0-3)

• For tumors extending beyond the oesophageal wall (T3) or involving nodes (N1), surgery remains an option 1
• Combined chemoradiotherapy is superior to radiotherapy alone for non-surgical treatment 1
• The RTOG schedule (four cycles of 5-FU-cisplatin and radiotherapy 50 Gy in 25 fractions over 5 weeks) is considered standard treatment for inoperable cases 1
• Surgery is not recommended for tumors involving mediastinal organs (T4) or with distant metastases 1

Metastatic Disease

• Chemotherapy for advanced oesophageal cancer is an option, but must be considered case by case 1
• Palliative interventions are recommended for non-resectable tumors or tumors with distant metastases 2

Treatment Modalities

Surgery

• Standard technique: subtotal transthoracic oesophagectomy with concurrent nodal clearance and gastroplasty 1
• Minimally invasive approaches (e.g., Ivor Lewis esophagectomy) are associated with decreased morbidity and shorter recovery times 3
• Proper lymph node dissection is essential, with removal of at least 15 lymph nodes recommended for adequate staging 3

Radiotherapy

• If chemotherapy is contraindicated, radiotherapy alone is recommended for advanced or inoperable cancers 1
• Pre- or postoperative radiotherapy alone is not recommended 1

Chemotherapy

• Adjuvant chemotherapy alone is not recommended 1
• For advanced disease, newer agents including taxanes and irinotecan have shown promising antitumor activity 4

Combined Chemoradiotherapy

• Combined modality therapy with radiotherapy and chemotherapy is superior to radiotherapy alone for non-surgical treatment 1
• Can be an alternative to surgery in operable disease that penetrates the wall of the oesophagus (T3) or involves nodes (N1) 1
• In adenocarcinomas of the oesophagus or oesophagogastric junction, preoperative chemoradiotherapy has shown efficacy 1

Immunotherapy

• Immune checkpoint inhibitor-based therapies have become established as standard of care in adjuvant and metastatic first-line settings 5

Treatment Algorithm

For Squamous Cell Carcinoma:

• Tis-T1a N0: Endoscopic resection or surgical resection 1
• T1-2 N0: Surgical resection 1
• T1-2 N+: Preoperative therapy followed by surgery 1
• T3-4 or N+: Combined chemoradiotherapy (may be followed by surgery) 1
• Unresectable or metastatic: Chemoradiotherapy or palliative care 1

For Adenocarcinoma:

• Tis-T1a N0: Endoscopic resection or surgical resection 1
• T1-2 N0: Surgical resection 1
• T1-2 N+ or T3-4: Preoperative chemoradiotherapy followed by surgery 1
• Unresectable or metastatic: Chemotherapy or palliative care 1

Important Considerations

• Long-term survival does not exceed 25% if regional lymph nodes are involved (pN1-3) 1
• Timely diagnosis and treatment are crucial - median time from diagnosis to treatment should ideally be less than 35 days 6
• Repeat gastroscopies can be prevented with clearer endoscopy guidelines 6
• Conversion from minimally invasive to open procedure may be necessary in approximately 7% of cases 3