From the Guidelines
Esophageal adenocarcinoma should be treated with a multimodal approach, including surgery, chemotherapy, and radiation, with the goal of improving survival rates and quality of life. The treatment of esophageal adenocarcinoma depends on the stage of cancer, with early-stage disease potentially being curative with endoscopic resection or surgery (esophagectomy) 1. For locally advanced disease, a combination of chemotherapy and radiation (chemoradiation) followed by surgery is often recommended, with common chemotherapy regimens including FOLFOX (5-fluorouracil, leucovorin, and oxaliplatin) or carboplatin with paclitaxel 1.
Diagnosis and Staging
The diagnosis of esophageal adenocarcinoma should be made from an endoscopic biopsy with histology according to the WHO criteria, with small-cell carcinomas identified and separated from squamous cell carcinomas and adenocarcinomas 1. Staging should include clinical examination, blood counts, liver and renal function tests, endoscopy, and a CT scan of chest and abdomen, with esophagogram and endoscopic ultrasound added for candidates for surgical resection 1.
Treatment Options
- Surgery is regarded as standard treatment only in carefully selected operable patients with localized tumors, with transthoracic esophagectomy with two-field resection recommended for intrathoracic squamous cell carcinoma 1.
- Preoperative chemoradiation or perioperative chemotherapy may be added to surgery to improve survival rates, with targeted therapies like trastuzumab and ramucirumab producing encouraging results in advanced or metastatic EGJ adenocarcinomas 1.
- For metastatic disease, systemic chemotherapy is the primary treatment, with regimens such as FOLFOX, FOLFIRI, or platinum-based combinations, and immunotherapy with checkpoint inhibitors like pembrolizumab may be considered for certain patients 1.
Risk Factors and Prognosis
Risk factors for esophageal adenocarcinoma include chronic gastroesophageal reflux disease, obesity, smoking, and alcohol consumption, with regular endoscopic surveillance recommended for patients with Barrett's esophagus to detect early malignant changes 1. The prognosis varies widely based on stage at diagnosis, with early detection significantly improving survival rates 1.
From the Research
Esophageal Adenocarcinoma Overview
- Esophageal cancer affects 1 in 125 men and 1 in 417 women, accounting for 2.6% of all cancer-related deaths in the United States 2
- The 5-year survival rate for localized disease is 46.4%, regional disease is 25.6%, and distant/metastatic disease is 5.2% 2
Staging and Treatment
- Endoscopic ultrasound (EUS) plays a key role in the locoregional staging of newly diagnosed esophageal adenocarcinoma and has an evolving role in restaging after neoadjuvant therapy 2
- Treatment is stage-dependent, with neoadjuvant therapy recommended for nonmetastatic transmural tumors (T3) and/or those with locoregional lymph node involvement (N), and upfront surgical resection for earlier tumors 2
- EUS is essential for identifying early stage disease and determining the need for induction therapy 3
Screening and Surveillance
- Screening for Barrett's esophagus, the only known precursor lesion of esophageal adenocarcinoma, is indicated for individuals with increased risk 4
- Endoscopic surveillance of patients with Barrett's esophagus likely improves overall outcomes, and endoscopic ablation and resection is highly effective for treating dysplastic Barrett's esophagus and early esophageal adenocarcinoma 4
Role of Endoscopic Ultrasound
- EUS is the most sensitive test for locoregional staging of esophageal cancer and influences the development of an optimal oncologic treatment plan 5
- EUS evaluation may detect suspicious lymph nodes prior to exposing the patient to the risks of endoscopic resection 5
- Multimodality staging with EUS, cross-sectional imaging, and histopathologic analysis remains the standard-of-care in the evaluation of early esophageal cancers 5
Diagnostic Tools
- Positron emission tomography (PET) has been increasingly utilized in staging esophageal cancer, but may be unnecessary for clinical staging of early, localized disease and carries the risk of false-positive metastasis (overstaging) 5
- The utility of PET, CT, and EUS to identify pathologic responders in esophageal cancer has been evaluated, with post-CRT PET SUV being the most accurate noninvasive test to predict long-term survival after preoperative CRT and before surgical resection 6