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.

Keywords: Esophageal cancer, Preoperative therapy, Multimodality treatment, Chemotherapy, Radiotherapy, Chemoradiotherapy

Core tip: The literature suggests that preoperative chemoradiotherapy followed by surgery results in optimal outcome while managing locally advanced esophageal cancer; however, there is a need to compare preoperative chemoradiotherapy with chemotherapy alone to further refine the role of preoperative therapy. The standard of care continues to be debated due to difference of opinions and practices across the world and lack of any trial with head-to-head comparison between these two established treatment protocols.