Surgery, radiotherapy, and chemotherapy for esophageal cancer

Abstract

Because endoscopic surveillance frequently fails to detect early cancer in Barrett's mucosa, the presence of high-grade dysplasia is considered as indication for “prophylactic” esophagectomy. Both transhiatal and transthoracic esophageal resection can be performed with acceptable morbidity and mortality. It is still unclear whether the disadvantages of an extended resection are outweighted by an increased disease-free interval or prolonged survival. Thoracoscopic esophagectomy probably cannot prevent the high pulmonary complication rate after a combined thoracoabdominal procedure. More promising results have been reported on laparoscopic lymphadenectomy and gastric mobilization with remarkably fast postoperative recovery. The interest in using chemoradiation either as neoadjuvant treatment of resectable esophageal carcinoma or as definitive nonsurgical treatment of locally advanced tumors is continuously increasing. A randomized study comparing chemoradiation plus surgery to surgery alone in resectable adenocarcinomas demonstrated a significant advantage of the combined treatment without increasing the postoperative complication rate. These results need to be confirmed but are very encouraging. The results of a similar prospective study in squamous cell carcinoma are awaited. A randomized study comparing surgery alone to surgery plus adjuvant chemotherapy did not demonstrate any advantage of the combined treatment; on the contrary the duration and quality of the survival was negatively influenced. It is still not clear whether response to chemotherapy could be used for selecting patients for either definitive chemoradiation or surgery.