Curative treatment of oesophageal carcinoma: current options and future developments
Maria C Wolf1*, Michael Stahl2, Bernd J Krause3,4, Luigi Bonavina5, Christiane Bruns6, Claus Belka1 and Franz Zehentmayr1
Abstract Since the 1980s major advances in surgery, radiotherapy andchemotherapy have established multimodal approaches as curative treatment options for oesophageal cancer. In addition the introduction of functional imaging modalities such as PET-CT created new opportunities for a more adequate patient selection and therapy response assessment. The majority of oesophageal carcinomas are represented by two histologies: squamous cell carcinoma and adenocarcinoma. Inrecent years an epidemiological shift towards the latter was observed. From a surgical point of view, adenocarcinomas, which are usually located in the distal third of the oesophagus, may be treated with a transhiatal resection, whereas squamous cell carcinomas, which are typically found in the middle and the upper third, require a transthoracic approach. Since overall survival after surgery aloneis poor, multimodality approaches have been developed. At least for patients with locally advanced tumors, surgery alone can no longer be advocated as routine treatment. Nowadays, scientific interest is focused on tumor response to induction radiochemotherapy. A neoadjuvant approach includes the early and accurate assessment of clinical response, optimally performed by repeated PET-CT imaging andendoscopic ultrasound, which may permit early adaption of the therapeutic concept. Patients with SCC that show clinical response by PET CT are considered to have a better prognosis, regardless of whether surgery will be performed or not. In non-responding patients salvage surgery improves survival, especially if complete resection is achieved. 1. Surgery In Western countries, the recentepidemiological shift from squamous cell carcinoma to adenocarcinoma arising in Barrett’s metaplasia has led to an increasing referral of patients with early oesophageal tumours detected during endoscopic surveillance . Squamous cell carcinoma (SCC) is associated with low socioeconomic status , active tobacco and alcohol abuse, malnutrition, liver dysfunction, pulmonary co-morbidities, and secondmalignancies . Patients with adenocarcinoma (AC) are characterized by co-morbidities such as coronary heart disease and a higher median age . AC is predominantly (94%) located in the lower third of the oesophagus, whereas 51% of SCC are found in the middle third and only 36% in the lower third. Moreover, a better prognosis with a
* Correspondence: firstname.lastname@example.org 1 Klinik undPoliklinik für Strahlentherapie und Radioonkologie, LudwigMaximilians Universität München, Germany Full list of author information is available at the end of the article
significantly higher overall survival after resection of AC than SCC was reported in some studies [5-7] whereas a SEER database review of 4752 patients showed no difference . However, the majority of patients still presentwith advanced disease and up to two thirds are inoperable at the time of diagnosis. Complete resection (R0), N- and T-stage are independent prognostic factors for SCC. Patients are categorised in risk groups by Karnofsky Performance Scale (KPS), cardiac function, liver and lung parameters . Preoperative improvement of nutritional status, abstention from tobacco and alcohol can decrease theperioperative risk. Patients with SCC of the cervical oesophagus, T1 2, with low surgical risk according to Bartels et al. , can be treated by a limited resection including regional lymphadenectomy and reconstruction using a free jejunal loop with microsurgical vessel anastomoses, whereas T3-4 patients are treated with neoadjuvant radiochemotherapy. Patients with a high perioperative risk get...