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  • Review Article
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Perioperative management of esophageal cancer

Nature Reviews Clinical Oncology volume 7, pages 231–238 (2010)Cite this article

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Abstract

There is no international consensus on the optimal management of operable esophageal cancer. Surgery alone is associated with a poor prognosis and is only appropriate in patients with very early-stage disease. Data from randomized phase III clinical trials support the use of neoadjuvant chemotherapy, neoadjuvant chemoradiation and perioperative chemotherapy for patients with adenocarcinomas of the esophagus and neoadjuvant chemotherapy, neoadjuvant chemoradiation or definitive chemoradiation for localized squamous cell carcinomas (SCC). Meta-analyses of published clinical trials have not assessed the role of perioperative chemotherapy and definitive chemoradiation, but have demonstrated a comparable survival benefit from neoadjuvant chemotherapy and chemoradiation for operable adenocarcinomas of the esophagus. A greater benefit for neoadjuvant chemoradiation compared with chemotherapy, however, was noted for localized SCC. In this Review, we discuss the data available from clinical trials and meta-analyses and how they inform current clinical practice.

Key Points

  • Neoadjuvant cisplatin plus fluoropyrimidine chemotherapy or chemoradiation is recommended for adenocarcinoma of the esophagus

  • Perioperative ECF chemotherapy is also a useful treatment option for patients with operable adenocarcinoma of the lower esophagus or esophagogastric junction

  • Patients with localized squamous cell carcinoma (SCC) of the esophagus should receive neoadjuvant or definitive chemoradiation

  • Surgery may be reserved for selected patients with locally persistent or relapsed SCC of the esophagus after definitive chemoradiation

  • Adjuvant chemoradiation should be considered for patients with positive resection margins after radical surgery

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Figure 1: A 58-year-old male with biopsy-proven primary lower oesophageal adenocarcinoma.
Figure 2: Axial fused color scale PET/CT data, demonstrating both functional and anatomical tumor extent.
Figure 3: Coronal fused color scale PET/CT data.
Figure 4: Sagittal fused color scale PET/CT data.

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References

  1. Parkin, D. M., Bray, F., Ferlay, J. & Pisani, P. Global cancer statistics, 202. CA Cancer J. Clin. 55, 74–108 (2005).

    Article  Google Scholar 

  2. Vizcaino, A. P., Moreno, V., Lambert, R. & Parkin, D. M. Time trends incidence of both major histologic types of esophageal carcinomas in selected countries, 1973–1995. Int. J. Cancer 99, 860–868 (2002).

    Article  CAS  Google Scholar 

  3. Kubo, A. & Corley, D. A. Body mass index and adenocarcinomas of the esophagus or gastric cardia: a systematic review and meta-analysis. Cancer Epidemiol. Biomarkers Prev. 15, 872–878 (2006).

    Article  Google Scholar 

  4. Walsh, T. N. et al. A comparison of multimodal therapy and surgery for esophageal adenocarcinoma. N. Engl. J. Med. 335, 462–467 (1996).

    Article  CAS  Google Scholar 

  5. Medical Research Council Oesophageal Cancer Working Group. Surgical resection with or without preoperative chemotherapy in oesophageal cancer: a randomised controlled trial. Lancet 359, 1727–1733 (2002).

  6. Cunningham, D. et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N. Engl. J. Med. 355, 11–20 (2006).

    Article  CAS  Google Scholar 

  7. Gebski, V. et al. Survival benefits from neoadjuvant chemoradiotherapy or chemotherapy in oesphageal carcinoma: a meta-analysis. Lancet Oncol. 8, 226–234 (2007).

    Article  CAS  Google Scholar 

  8. Bedenne, L. et al. Chemoradiation followed by surgery compared with chemoradiation alone in squamous cancer of the esophagus: FFCD 9102. J. Clin. Oncol. 25, 1160–1168 (2007).

    Article  CAS  Google Scholar 

  9. Stahl, M. et al. Chemoradiation with and without surgery in patients with locally advanced squamous cell carcinoma of the esophagus. J. Clin. Oncol. 23, 2310–2317 (2005).

    Article  Google Scholar 

  10. Kelsen, D. P. et al. Chemotherapy followed by surgery compared with surgery alone for localized esophageal cancer. N. Engl. J. Med. 339, 1979–1984 (1998).

    Article  CAS  Google Scholar 

  11. Allum, W. H., Stenning, S. P., Bancewicz, J., Clark, P. I. & Langley, R. E. Long-term results of a randomized trial of surgery with or without preoperative chemotherapy in esophageal cancer. J. Clin. Oncol. 27, 5062–5067 (2009).

    Article  Google Scholar 

  12. Tepper, J. et al. Phase III trial of trimodality therapy with cisplatin, fluorouracil, radiotherapy, and surgery compared with surgery alone for esophageal cancer: CALGB 9781. J. Clin. Oncol. 26, 1086–1092 (2008).

    Article  CAS  Google Scholar 

  13. Stahl, M. et al. Phase III comparison of preoperative chemotherapy compared with chemoradiotherapy in patients with locally advanced adenocarcinoma of the esophagogastric junction. J. Clin. Oncol. 27, 851–856 (2009).

    Article  CAS  Google Scholar 

  14. Burmeister, B. H. et al. Surgery alone versus chemoradiotherapy followed by surgery for resectable cancer of the oesophagus: a randomised controlled phase III trial. Lancet Oncol. 6, 659–668 (2005).

    Article  Google Scholar 

  15. Ott, K. et al. Metabolic imaging predicts response, survival, and recurrence in adenocarcinomas of the esophagogastric junction. J. Clin. Oncol. 24, 4692–4698 (2006).

    Article  Google Scholar 

  16. Lordick, F. et al. PET to assess early metabolic response and to guide treatment of adenocarcinoma of the oesophagogastric junction: the MUNICON phase II trial. Lancet Oncol. 8, 797–805 (2007).

    Article  Google Scholar 

  17. Cunningham, D. et al. Capecitabine and oxaliplatin for advanced esophagogastric cancer. N. Engl. J. Med. 358, 36–46 (2008).

    Article  CAS  Google Scholar 

  18. Bamias, A. et al. Adjuvant chemotherapy for oesophagogastric cancer with epirubicin, cisplatin and infusional 5-fluorouracil (ECF): a Royal Marsden pilot study. Br. J. Cancer 71, 583–586 (1995).

    Article  CAS  Google Scholar 

  19. Armanios, M. et al. Adjuvant chemotherapy for resected adenocarcinoma of the esophagus, gastro-esophageal junction, and cardia: phase II trial (E8296) of the Eastern Cooperative Oncology Group. J. Clin. Oncol. 22, 4495–4499 (2004).

    Article  CAS  Google Scholar 

  20. Liu, H. C. et al. Esophagectomy for locally advanced esophageal cancer, followed by chemoradiotherapy and adjuvant chemotherapy. World J. Gastroenterol. 11, 5367–5372 (2005).

    Article  Google Scholar 

  21. Kelsen, D. P. et al. Long-term results of RTOG trial 8911 (USA Intergroup 113): a random assignment trial comparison of chemotherapy followed by surgery compared with surgery alone for esophageal cancer. J. Clin. Oncol. 25, 3719–3725 (2007).

    Article  Google Scholar 

  22. The Medical Research Council Oesophageal Cancer Working Group. Surgical resection with or without preoperative chemotherapy in oesophageal cancer: a randomised controlled trial. Lancet 359, 1727–1733 (2002).

  23. Nygaard, K. et al. Pre-operative radiotherapy prolongs survival in operable esophageal carcinoma: a randomized, multicenter study of pre-operative radiotherapy and chemotherapy. The second Scandinavian trial in esophageal cancer. World J. Surg. 16, 1104–1109 (1992).

    Article  CAS  Google Scholar 

  24. Bosset, J. F. et al. Chemoradiotherapy followed by surgery compared with surgery alone in squamous-cell cancer of the esophagus. N. Engl. J. Med. 337, 161–167 (1997).

    Article  CAS  Google Scholar 

  25. Lee, J. L. et al. A single institutional phase III trial of preoperative chemotherapy with hyperfractionation radiotherapy plus surgery versus surgery alone for resectable esophageal squamous cell carcinoma. Ann. Oncol. 15, 947–954 (2004).

    Article  CAS  Google Scholar 

  26. Le Prise, E. et al. A randomized study of chemotherapy, radiation therapy, and surgery versus surgery for localized squamous cell carcinoma of the esophagus. Cancer 73, 1779–1784 (1994).

    Article  CAS  Google Scholar 

  27. Urschel, J. D. & Vasan, H. A meta-analysis of randomized controlled trials that compared neoadjuvant chemoradiation and surgery to surgery alone for resectable esophageal cancer. Am. J. Surg. 185, 538–543 (2003).

    Article  Google Scholar 

  28. Fiorica, F. et al. Preoperative chemoradiotherapy for oesophageal cancer: a systematic review and meta-analysis. Gut 53, 925–930 (2004).

    Article  CAS  Google Scholar 

  29. Chiu, P. W. et al. Multicenter prospective randomized trial comparing standard esophagectomy with chemoradiotherapy for treatment of squamous esophageal cancer: early results from the Chinese University Research Group for Esophageal Cancer (CURE). J. Gastrointest. Surg. 9, 794–802 (2005).

    Article  Google Scholar 

  30. Borghesi, S., Hawkins, M. A. & Tait, D. Oesophagectomy after definitive chemoradiation in patients with locally advanced oesophageal cancer. Clin. Oncol. (R. Coll. Radiol.) 20, 221–226 (2008).

    Article  CAS  Google Scholar 

  31. Ando, N. et al. Surgery plus chemotherapy compared with surgery alone for localized squamous cell carcinoma of the thoracic esophagus: a Japan Clinical Oncology Group Study—JCOG9204. J. Clin. Oncol. 21, 4592–4596 (2003).

    Article  Google Scholar 

  32. Zhang, J., Chen, H. Q., Zhang, Y. W. & Xiang, J. Q. Adjuvant chemotherapy in oesophageal cancer: a meta-analysis and experience from the Shanghai Cancer Hospital. J. Int. Med. Res. 36, 875–882 (2008).

    Article  CAS  Google Scholar 

  33. Zieren, H. U. et al. Adjuvant postoperative radiation therapy after curative resection of squamous cell carcinoma of the thoracic esophagus: a prospective randomized study. World J. Surg. 19, 444–449 (1995).

    Article  CAS  Google Scholar 

  34. Tachibana, M. et al. Postoperative chemotherapy vs chemoradiotherapy for thoracic esophageal cancer: a prospective randomized clinical trial. Eur. J. Surg. Oncol. 29, 580–587 (2003).

    Article  CAS  Google Scholar 

  35. Apinop, C., Puttisak, P. & Preecha, N. A prospective study of combined therapy in esophageal cancer. Hepatogastroenterology 41, 391–393 (1994).

    CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Medicine, The Royal Marsden Hospital, Downs Road, Sutton, SM2 5PT, Surrey, UK

    Alicia Okines, Bhupinder Sharma & David Cunningham

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  1. Alicia Okines
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  2. Bhupinder Sharma
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  3. David Cunningham
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Corresponding author

Correspondence to David Cunningham.

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Competing interests

Alicia Okines declares she is on the speaker's bureau for Roche. David Cunningham declares he receives grant/research support from Roche. Bhupinder Sharma declares no competing interests.

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Okines, A., Sharma, B. & Cunningham, D. Perioperative management of esophageal cancer. Nat Rev Clin Oncol 7, 231–238 (2010). https://doi.org/10.1038/nrclinonc.2010.20

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