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  • Review Article
  • Published:

Treatment for unresectable or metastatic oesophageal cancer: current evidence and trends

Key Points

  • In patients with unresectable or metastatic oesophageal carcinoma, the best possible outcomes are achieved through an individualized approach by a multidisciplinary team

  • Treatment aims to relieve dysphagia and other cancer-related symptoms, to improve quality of life and to prolong survival while minimizing risks and toxicity

  • Concurrent chemoradiotherapy is the preferred treatment option for patients with inoperable or unresectable, locally advanced disease

  • Palliative combination chemotherapy and targeted therapy should be considered in patients with distant metastatic disease.

  • Local treatment options for malignant dysphagia include various endoscopic and radiotherapeutic approaches carrying specific advantages and disadvantages, with no absolute superiority of any particular intervention

  • Ongoing trends involve improvements in radiotherapy and endoscopic techniques, cytotoxic compound substitutions, introduction of targeted therapies and immunotherapy, identification of predictive biomarkers and effective combination strategies and shifts towards curative intent

Abstract

Approximately half of the patients diagnosed with oesophageal cancer present with unresectable or metastatic disease. Treatment for these patients aims to control dysphagia and other cancer-related symptoms, improve quality of life and prolong survival. In the past 25 years, modestly improved outcomes have been achieved in the treatment of patients with inoperable non-metastatic cancer who are medically not fit for surgery or have unresectable, locally advanced disease. Concurrent chemoradiotherapy offers the best outcomes in these patients. In distant metastatic oesophageal cancer, several double-agent or triple-agent chemotherapy regimens have been established as first-line treatment options. In addition, long-term results of multiple large randomized phase III trials using additional targeted therapies have been published in the past few years, affecting contemporary clinical practice and future research directions. For the local treatment of malignant dysphagia, various treatment options have emerged, and self-expandable metal stent (SEMS) placement is currently the most widely applied method. Besides the continuous search for improved SEMS designs to minimize the risk of associated complications, efforts have been made to develop and evaluate the efficacy of antireflux stents and irradiation stents. This Review outlines the current evidence and ongoing trends in the different modern-day, multidisciplinary interventions for patients with unresectable or metastatic oesophageal cancer with an emphasis on key randomized trials.

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Figure 1: Management of a patient with unresectable or metastatic oesophageal cancer by a multidisciplinary team.
Figure 2: Use of a self-expandable metal stent for dysphagia caused by an obstructing oesophageal tumour.
Figure 3: Management of a malignant oesophagorespiratory fistula by use of a self-expanding metal stent.
Figure 4: Chemoradiotherapy and resection in a patient with initially unresectable ESCC.

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P.S.N.v.R. wrote the article. All of the authors researched data for the article, made substantial contributions to discussion of content and edited the manuscript before submission.

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van Rossum, P., Mohammad, N., Vleggaar, F. et al. Treatment for unresectable or metastatic oesophageal cancer: current evidence and trends. Nat Rev Gastroenterol Hepatol 15, 235–249 (2018). https://doi.org/10.1038/nrgastro.2017.162

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