Standard Treatment Approach for Oesophageal Cancer
Treatment of oesophageal cancer must be stratified by disease stage and histological type, with surgery alone for early-stage disease (Tis-T2 N0), preoperative chemoradiotherapy followed by surgery for locally advanced disease (T3-T4), and definitive chemoradiotherapy or palliative therapy for metastatic disease. 1
Diagnosis and Staging Requirements
Before initiating treatment, establish diagnosis through endoscopic biopsy with WHO classification to distinguish squamous cell carcinoma (SCC), adenocarcinoma (AC), and small cell carcinoma, as these require different treatment approaches 2. Complete staging must include:
- Clinical examination with nutritional assessment, blood counts, and liver/renal function tests 2
- CT scan of chest and abdomen 2
- Endoscopic ultrasound for surgical candidates to evaluate T and N stage 2
- PET scan to identify occult distant metastases 2
- Laparoscopy for T3/T4 adenocarcinomas of the esophagogastric junction to rule out peritoneal metastases 2
- Bronchoscopy for upper/mid-thoracic tumours to exclude tracheo-bronchial involvement 2
Treatment Algorithm by Stage
Early Cancer (Tis-T1a N0)
Surgery is the definitive treatment of choice for superficial tumours confined to the mucosa 2, 1. Endoscopic resection provides equivalent cure rates in specialized centers for highly selected patients 1.
Localized Disease (T1-2 N0-1 M0)
Surgery remains the standard treatment for localized disease 2, 1. For intrathoracic SCC, perform transthoracic esophagectomy with two-field lymph node resection, ensuring at least six regional lymph nodes are examined 2, 1.
For patients unable or unwilling to undergo surgery, combined chemoradiotherapy is superior to radiotherapy alone 2, 1. For adenocarcinoma with suspected lymph node involvement (T1-2 N1-3), preoperative therapy is recommended before surgery 1.
Locally Advanced Disease (T3-T4 N0-1)
Surgery alone is inadequate because complete resection is impossible in 30% of pT3 and 50% of pT4 tumours 2, 1. The treatment approach diverges by histology:
For Adenocarcinoma:
Preoperative chemotherapy (cisplatin/5-fluorouracil) with or without radiotherapy followed by surgery is the preferred approach 2, 1. Perioperative chemotherapy (pre- and postoperative) is an established option for lower esophageal/esophagogastric junction adenocarcinomas 2.
For Squamous Cell Carcinoma:
Preoperative chemoradiotherapy improves complete resection rates, local control, and survival 2, 1. However, a critical alternative exists: definitive chemoradiotherapy with close surveillance and salvage surgery for relapse may be considered instead of planned surgery, particularly for upper third tumours, as this achieves similar overall survival with less morbidity 2, 1. This approach is supported by French (FFCD 9102) and German trials showing patients with good morphological response to chemoradiotherapy may not benefit from surgery 2.
Important caveat: Preoperative chemoradiotherapy may increase postoperative mortality, requiring careful patient selection 2, 1.
Metastatic Disease (Stage IV)
Treatment is strictly palliative 2, 1. Chemotherapy may be offered to selected patients with good performance status 2, 1. For dysphagia relief, esophageal stenting provides rapid restoration of oral nutrition, though single-dose 12 Gy intracavitary brachytherapy may provide superior long-term dysphagia control 2, 1.
Critical Treatment Principles
Preoperative or postoperative radiotherapy alone (without chemotherapy) does not improve survival and is not recommended 2. This is level I, grade A evidence and represents a clear contraindication 2.
Adjuvant chemotherapy or chemoradiotherapy after surgery alone is not recommended except for lower esophageal/esophagogastric junction adenocarcinomas after limited surgery 2.
Primary interdisciplinary planning is mandatory before initiating any treatment 2. Surgery should only be performed in experienced centers with low operative mortality and morbidity 3.
Follow-Up Approach
Regular surveillance after initial therapy has not been proven to influence outcomes 2. Focus follow-up visits on symptom management, nutritional support, and psychosocial problems rather than routine imaging 2.
Common Pitfalls to Avoid
Do not offer surgery for T4 tumours involving mediastinal organs or M1 disease 2. Do not use preoperative radiotherapy without concurrent chemotherapy 2. Do not proceed with planned surgery in SCC patients who achieve complete clinical response to chemoradiotherapy, as definitive chemoradiotherapy with surveillance may provide equivalent survival with less morbidity 2.