title: The current evidence in support of multimodal treatment of locally advanced, potentially resectable esophageal cancer.
abstract: BACKGROUND
  Treatment of locally advanced resectable esophageal cancer is challenging. In the past three decades surgical treatment has become safer, chemotherapy more powerful and radiation techniques more precise. Today's stage-dependent treatment relies on modern diagnostic tools such as multidetector helical CT, high-frequency endoscopic ultrasound, PET, image fusion techniques and MRI. Specialists cooperate on multidisciplinary tumor boards that follow transparent decision trees based on the newest evidence.
  
  
  METHODS
  Results of recent randomized controlled trials are examined with emphasis on their reliability and comparability.
  
  
  RESULTS
  Patients with esophagogastric cancer undergoing neoadjuvant chemotherapy, perioperative chemotherapy and neoadjuvant radiochemotherapy plus esophagectomy had a higher R-0 resection rate, fewer involved lymph nodes and better overall survival than with esophagectomy alone. While perioperative morbidity and mortality were not remarkably enhanced by neoadjuvant chemotherapy, several trials showed an increase of mortality after neoadjuvant radiochemotherapy. Adenocarcinoma seems to respond better to chemotherapy than squamous cell cancer, and squamous cell cancer seems to respond better to radiochemotherapy than adenocarcinoma.
  
  
  CONCLUSIONS
  On the basis of the results of randomized trials, preoperative treatment of esophageal cancer shows a survival benefit and should be recommended as the standard treatment strategy in advanced esophageal cancer. While preoperative radiochemotherapy is the standard for advanced squamous cell cancer, both chemotherapy and radiochemotherapy may be adopted for neoadjuvant/perioperative treatment of adenocarcinoma depending on the patient's general condition. Markers to predict response are urgently needed since only responders benefit from multimodal treatment and nonresponders suffer potential harm when surgery is delayed.
authors.affiliation: Center for Esophageal and Gastric Surgery, Division of General Surgery, Herz-Jesu Krankenhaus, Vienna, Austria.
authors.forename: Johannes
authors.initials: J
authors.lastname: Zacherl
mesh_terms: D014408:Biomarkers, Tumor / Q000378:metabolism; D059248:Chemoradiotherapy; D003131:Combined Modality Therapy; D004938:Esophageal Neoplasms / Q000188:drug therapy / Q000473:pathology* / Q000532:radiotherapy / Q000628:therapy*; D006801:Humans; D009367:Neoplasm Staging; D016032:Randomized Controlled Trials as Topic
chemical_list: D014408:Biomarkers, Tumor