Preoperative therapy in locally advanced esophageal cancer

Abstract

Esophageal cancer is an aggressive malignancy associated with dismal treatment outcomes. Presence of two distinct histopathological types distinguishes it from other gastrointestinal tract malignancies. Surgery is the cornerstone of treatment in locally advanced esophageal cancer (T2 or greater or node positive); however, a high rate of disease recurrence (systemic and loco-regional) and poor survival justifies a continued search for optimal therapy. Various combinations of multimodality treatment (preoperative/perioperative, or postoperative; radiotherapy, chemotherapy, or chemoradiotherapy) are being explored to lower disease recurrence and improve survival. Preoperative therapy followed by surgery is presently considered the standard of care in resectable locally advanced esophageal cancer as postoperative treatment may not be feasible for all the patients due to the morbidity of esophagectomy and prolonged recovery time limiting the tolerance of patient. There are wide variations in the preoperative therapy practiced across the centres depending upon the institutional practices, availability of facilities and personal experiences. There is paucity of literature to standardize the preoperative therapy. Broadly, chemoradiotherapy is the preferred neo-adjuvant modality in western countries whereas chemotherapy alone is considered optimal in the far East. The present review highlights the significant studies to assist in opting for the best evidence based preoperative therapy (radiotherapy, chemotherapy or chemoradiotherapy) for locally advanced esophageal cancer.

RBBP6 increases radioresistance and serves as a therapeutic target for preoperative radiotherapy in colorectal cancer

“…Radiotherapy has been established as an effective local treatment for carcinomas . Preoperative radiotherapy is a promising treatment option to downstage initially unresectable tumors, increase the resection rate and improve the overall survival of patients, especially for patients with low rectal cancer .…”

Locally Advanced Esophageal Cancer: State of the Art

“…The presence of micrometastasis that leads to failure in curatively treated patients guided the investigation to explore the role of induction preoperative chemotherapy. The aim of preoperative chemotherapy is exterminating micrometastasis, downstage the tumor enhancing resectability, improve locoregional control and finally improve overall survival (8). But on the other hand, it exists the risk of progression disease and compromising definitive treatment.…”

Pre-operative treatments for adenocarcinoma of the lower oesophagus and gastro-oesophageal junction: a review of the current evidence from randomized trials

“…Exclusive RT in the neoadjuvant setting has been used in oesophageal cancer in the attempt to ameliorate the rate of negative circumferential margin during radical resections, to lower the rate of loco-regional failure and to improve survival [8]. Five randomized phase III trials investigated whether pre-operative RT followed by surgery might be more effective compared to surgery alone [8].…”

“…Pre-operative CT was shown to provide tumour downsizing and downstaging, to improve resectability rates, to eradicate micrometastatic disease, to improve loco-regional control and survival in oesophageal and GEJ tumours [8]. The meta-analysis by Sjoquist et al [12] reported that the all-cause mortality was significantly lower in patients submitted to pre-operative CT before surgery over surgery alone (HR 0.87; 95% CI 0.79-0.96; p = 0.005), with an estimated 5.1% survival difference at 2 years.…”

“…Five randomized phase III trials investigated whether pre-operative RT followed by surgery might be more effective compared to surgery alone [8]. A metaanalysis based on individual patient data enrolled in these trials demonstrated an hazard ratio (HR) of 0.89 (95% CI 0.78-1.01) by the addition of RT, suggesting a 11% overall reduction in the risk of death and an absolute survival benefit of 3% at 2 years and 4% at 5 years, with borderline statistical significance (p = 0.062) [9].…”