Elsevier

The Lancet Oncology

Volume 8, Issue 6, June 2007, Pages 545-553
The Lancet Oncology

Review
Therapeutic strategies in oesophageal carcinoma: role of surgery and other modalities

https://doi.org/10.1016/S1470-2045(07)70172-9Get rights and content

Summary

Traditionally, surgery is considered the best treatment for oesophageal cancer in terms of locoregional control and long-term survival. However, survival 5 years after surgery alone is about 25%, and, therefore, a multidisciplinary approach that includes surgery, radiotherapy, and chemotherapy, alone or in combination, could prove necessary. The role of each of these treatments in the management of oesophageal cancer is under intensive research to define optimum therapeutic strategies. In this report we provide an update on treatment strategies for resectable oesophageal cancers on the basis of recent published work. Results of the latest randomised trials allow us to propose the following guidelines: surgery is the standard treatment, to be used alone for stages I and IIa, or possibly with neoadjuvant chemotherapy or chemoradiotherapy for stage IIb disease. For locally advanced cancers (stage III), neoadjuvant chemotherapy or chemoradiotherapy followed by surgery is appropriate for adenocarcinomas. Chemoradiotherapy alone should only be considered in patients with squamous-cell carcinomas who show a morphological response to chemoradiotherapy, and produces a similar overall survival to chemoradiotherapy followed by surgery, but with less post-treatment morbidity. Although the addition of surgery to chemotherapy or chemoradiotherapy could result in improved local control and survival, surgery should be done in experienced hospitals where operative mortality and morbidity are low. Moreover, surgery should be kept in mind as salvage treatment in patients with no morphological response or persistent tumour after definitive chemoradiotherapy.

Introduction

Oesophageal cancer (figure 1) is the ninth most frequent cancer in the world and the fifth most frequent cancer in developed countries and incidence is increasing in rapidly because of an increase in adenocarcinomas of the lower oesophagus. Despite substantial improvements in screening, diagnosis, and treatment of this tumour, the prognosis is bleak. At the time of diagnosis, two of three patients will have tumours that are considered inoperable because of patient comorbidities or tumour extension. After surgical exploration, surgical resection is finally possible in just 15–20% of patients. Survival at 5 years for all patients, whether they have undergone surgery or not, is less than 10%.1

Many therapeutic options are used to treat oesophageal cancer, but traditionally surgery is used most frequently to obtain locoregional control and long-term survival. However, a multidisciplinary approach, including surgery, radiotherapy, and chemotherapy, alone or in combination, will be necessary to improve the outlook for patients with this disease. As a result of the scarcity of randomised trials on this cancer, the importance of the above treatments in the management of oesophageal cancer and the optimum therapeutic strategies for different stages of this disease have still not been resolved.

Section snippets

Surgery

Surgical resection is a standard treatment option for oesophageal cancer, usually undertaken by right transthoracic or transhiatal approaches. Transthoracic resection involves a laparotomy and a right thoracotomy with upper thoracic (Lewis-Santy) or cervical anastomosis (figure 2). Although this approach allows en-bloc resection of the tumour and lymph nodes under sight control, the risk of cardiorespiratory complications is high. Transhiatal resection involves a mediastinal blind dissection

Combination of surgery, neoadjuvant treatments, and adjuvant treatments

Radiotherapy and chemotherapy could improve the control of local or general disease by downstaging cancer (and thereby increasing resectability), eradicating micrometastatic disease, decreasing cancer-cell dissemination during intervention, and by complimenting another treatment modality without effecting postoperative mortality and morbidity. In the following studies, response to neoadjuvant treatment was generally defined as a partial or complete morphological response according to Response

Treatment without surgery

Because of the high incidence of postoperative complications, many researchers have investigated whether oesophagectomy is necessary after neoadjuvant chemoradiotherapy. In phase II trials that have investigated chemoradiotherapy alone, local control varied from 40% to 75%, median overall survival from 9 to 24 months and 5-year survival from 18% to 40%.54, 55, 56, 57, 58, 59

Conclusion

Despite flaws in the methodology of most studies discussed here and the controversial findings regarding survival benefit, improvements in postoperative morbidity and mortality, and tumour response, the following therapeutic strategies for oesophageal carcinoma can be proposed on the basis of this review of the published work: surgery alone is the standard treatment for stages I (T1N0) and IIa (T2–T3N0), or in combination with neoadjuvant chemotherapy or chemoradiotherapy for stages IIb

Search strategy and selection criteria

Data for this review were identified by searches of MEDLINE, Cancerlit, EMBASE, and references from relevant articles, using the search terms “randomised trial”, “oesophageal cancer”, “treatment”, “surgery”, “radiotherapy”, “chemotherapy” and “chemoradiotherapy”. Data related with gastroesophageal junction carcinoma were not included because of a recognised specific therapeutic approach. Abstracts and reports from meetings were included only when they related directly to previously

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