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
ReviewTherapeutic strategies in oesophageal carcinoma: role of surgery and other modalities
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
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