Locally advanced esophageal cancer.
Patients diagnosed with adenocarcinoma or squamous cell carcinoma of the esophagus should undergo computed tomography of the chest and abdomen and positron emission tomography to look for evidence of distant metastatic disease. In the absence of systemic metastases, locoregional staging should be performed with endoscopic ultrasonography and fine needle aspiration of accessible periesophageal lymph nodes and any detectable celiac lymph nodes. Patients found to have T3 tumors (transmural extension), T4 tumors (invasion of adjacent structures), or N1-M1a (lymph node-positive) disease do poorly when treated with surgery alone; 5-year survival is less than 20%. These patients should be considered for combined modality therapy. Patients with T4 disease are generally not deemed candidates for surgical resection; they may be considered for definitive chemoradiotherapy. Patients with T3 disease or lymph node-positive disease may be treated with neoadjuvant chemoradiotherapy followed by surgery or definitive chemoradiotherapy alone. Patients considered for trimodality therapy should be fully restaged before surgery to assess their response to neoadjuvant treatment. This should include repeat endoscopic ultrasound and fine needle aspiration of lymph nodes. Patients whose lymph node metastases do not completely respond to neoadjuvant therapy are unlikely to benefit from the addition of surgery. Patients with persistently positive celiac lymph nodes have a very poor prognosis and should not undergo surgery. Patients with persistent nodal disease who have good performance status may be considered for additional chemotherapy. Patients with locally advanced esophageal cancer who have poor performance status are not good candidates for combined modality therapy. These individuals are best managed with palliative intent. Particular attention should be given to alleviating the common problem of dysphagia, which causes significant morbidity.
Sherman
Carol A
CA
Hollings Cancer Center, Medical University of South Carolina, 86 Jonathan Lucas Street, Charleston, SC 29425, USA. shermanc@musc.edu
Turrisi
Andrew T
AT
Wallace
Michael B
MB
Reed
Carolyn E
CE
D000970:Antineoplastic Agents / Q000627:therapeutic use; D002277:Carcinoma / Q000175:diagnosis / Q000473:pathology* / Q000628:therapy*; D003131:Combined Modality Therapy; D004938:Esophageal Neoplasms / Q000175:diagnosis / Q000473:pathology* / Q000628:therapy*; D016629:Esophagectomy; D006801:Humans; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D010166:Palliative Care; D011878:Radiotherapy; D015607:Stents
D000970:Antineoplastic Agents