What is the recommended treatment approach for a patient with locally advanced esophageal adenocarcinoma?

Treatment Approach for Locally Advanced Esophageal Adenocarcinoma

For patients with locally advanced esophageal adenocarcinoma, preoperative chemoradiotherapy is the preferred treatment approach, as it provides significant survival benefit compared to surgery alone. 1

Initial Staging and Assessment

• Complete staging workup should include endoscopic ultrasound (EUS) to accurately determine T and N stage, which guides treatment decisions 1
• CT scan of chest and abdomen is essential to evaluate for distant metastases 2
• PET/CT is recommended to identify otherwise undetected distant metastases 2
• For adenocarcinomas of the esophagogastric junction, laparoscopy can rule out peritoneal metastases 2
• Nutritional assessment and optimization should be performed prior to initiating therapy 1

Treatment Options for Locally Advanced Disease

Preoperative Chemoradiotherapy (Preferred Approach)

• Preoperative chemoradiotherapy provides significant survival benefit for patients with locally advanced adenocarcinoma, particularly in high-risk patients with more advanced stages 2
• Recommended regimens include:
  • Weekly carboplatin and paclitaxel with concurrent radiation (41.4-50.4 Gy in 1.8-2.0 Gy fractions) 2, 1
  • Cisplatin/5-FU combined with radiation (41.4-50.4 Gy in 1.8-2.0 Gy fractions) 2
• This approach increases rates of complete tumor resection, improves local tumor control, and enhances survival 2

Perioperative Chemotherapy (Alternative Approach)

• FLOT regimen (docetaxel, oxaliplatin, leucovorin, and fluorouracil) is the standard of care for perioperative chemotherapy 3
• Standard duration is 4 preoperative cycles (8 weeks) followed by surgery and 4 postoperative cycles 3
• Particularly suitable for smaller tumors at the gastroesophageal junction 1, 3
• If FLOT is not available, cisplatin and fluorouracil (CF) can be used as an alternative 3

Surgical Approach

• Transthoracic esophagectomy with two-field lymphadenectomy is recommended for intrathoracic adenocarcinoma 2, 1
• Surgery should proceed even after complete clinical response to preoperative therapy 2, 3
• Adequate lymphadenectomy with a goal of obtaining at least 16-18 (preferably 20) lymph nodes is crucial 3

Post-Treatment Management

• Adjuvant nivolumab should be administered if the patient received preoperative chemoradiotherapy and has residual disease in the resection specimen 1
• If perioperative chemotherapy was used, completion of the remaining postoperative cycles is essential 1, 3
• Regular surveillance with imaging and endoscopy is recommended for monitoring disease recurrence 1

Special Considerations

• For patients unable to undergo surgery, definitive chemoradiotherapy with at least 50.4 Gy in 1.8 Gy fractions is recommended 2, 1
• For patients with cervically located tumors, definitive chemoradiotherapy is recommended 2
• Patients with tracheoesophageal fistula or airway compromise may require airway stenting before initiating definitive therapy 4

Factors Influencing Treatment Selection

• Factors favoring preoperative chemoradiotherapy:
  • Larger tumor size
  • More proximal extension
  • Concern for achieving complete surgical resection 1
• Factors favoring perioperative chemotherapy:
  • Smaller tumor size
  • Higher likelihood of complete surgical resection
  • Patient inability to tolerate radiation therapy 1

Common Pitfalls to Avoid

• Delaying treatment in patients with dysphagia, which can lead to nutritional compromise 1, 4
• Proceeding with surgery alone, which is suboptimal as complete tumor resection is not possible in approximately 30% of pT3 and 50% of pT4 tumors 2
• Failing to address airway compromise in patients with advanced disease, which can lead to rapid deterioration 4
• Placing an esophageal stent before airway stent in patients with both esophageal obstruction and airway compromise 4