Treatment Options for Esophageal Cancer
The treatment of esophageal cancer should be based on tumor stage, histological type, and patient fitness, with surgery as the standard treatment for early-stage disease (Tis-T2 N0), preoperative chemoradiotherapy for locally advanced disease (T3-T4 N0-1), and palliative approaches for metastatic disease. 1
Diagnosis and Staging
- Diagnosis requires endoscopic biopsy with histology classified according to WHO criteria, distinguishing between squamous cell carcinoma (SCC), adenocarcinoma (AC), and small cell carcinoma 1
- Comprehensive staging should include:
- Clinical examination, blood counts, liver, pulmonary, and renal function tests 1
- Endoscopy (including upper-aerodigestive tract endoscopy for tumors at/above tracheal bifurcation) 1
- CT scan of chest and abdomen 1
- Endoscopic ultrasound and PET-CT for surgical candidates to evaluate T and N categories 1
- Laparoscopy for locally advanced (T3/T4) adenocarcinomas of the esophagogastric junction to rule out peritoneal metastases 1
Treatment by Disease Stage
Early Cancer (Tis-T1a N0)
- Surgery is the treatment of choice 1
- Endoscopic resection is a viable alternative for selected patients, with similar cure rates in specialized centers 1
Localized Disease (T1-2 N0-1 M0)
- Surgery is the standard treatment 1
- For patients unable or unwilling to undergo surgery, combined chemoradiotherapy is superior to radiotherapy alone 1
- For adenocarcinoma with suspected lymph node involvement (T1-2 N1-3 M0), preoperative therapy is recommended 1
Locally Advanced Disease (T3-T4 N0-1)
- Surgery alone is suboptimal since complete tumor resection is not possible in approximately 30% of pT3 and 50% of pT4 tumors 1
- Patients benefit from preoperative therapy:
- Preoperative chemoradiotherapy confers a survival benefit according to meta-analyses 1
- For adenocarcinoma, cisplatin/5-fluorouracil combined with radiotherapy followed by surgery is considered the best option 1
- Patients with good tumor response to initial chemoradiotherapy may not require surgery and can be treated with definitive chemoradiotherapy 1
- Preoperative chemotherapy without radiation is an option for adenocarcinomas of the lower esophagus and esophagogastric junction 1
Metastatic Disease (Stage IV)
Treatment by Histological Type
Squamous Cell Carcinoma (SCC)
- Surgery is the standard treatment for operable patients, though long-term survival does not exceed 25% when regional lymph nodes are involved 1
- For patients unable or unwilling to undergo surgery, chemoradiotherapy is superior to radiotherapy alone 1
- Preoperative chemoradiotherapy improves rates of complete tumor resection, local tumor control, and survival 1
Adenocarcinoma (AC)
- Surgery is routinely used, with similar survival limitations as SCC 1
- Cisplatin/5-fluorouracil combined with radiotherapy followed by surgery is considered the best option for locally advanced disease 1
- Preoperative (and postoperative) chemotherapy is a treatment option for ACs of the lower esophagus and esophagogastric junction 1
Chemotherapy Regimens
- Cisplatin and 5-fluorouracil-based regimens are standard 2
- Newer agents showing efficacy include:
Important Considerations
- Primary interdisciplinary planning of treatment is mandatory 1
- Patient fitness significantly impacts treatment options - consider performance status, respiratory function, and comorbidities 1
- Preoperative chemoradiotherapy may increase postoperative mortality, requiring careful patient selection 1
- Regular follow-up after initial therapy has not been shown to influence outcomes; follow-up visits should focus on symptoms, nutrition, and psychosocial problems 1