Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Oct 21, 2016; 22(39): 8750-8759
Published online Oct 21, 2016. doi: 10.3748/wjg.v22.i39.8750
Preoperative therapy in locally advanced esophageal cancer
Pankaj Kumar Garg, Jyoti Sharma, Ashish Jakhetiya, Aakanksha Goel, Manish Kumar Gaur
Pankaj Kumar Garg, Aakanksha Goel, Manish Kumar Gaur, Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi 110095, India
Jyoti Sharma, Department of Surgical Oncology, Sawai Man Singh Medical College, Jaipur 302004, India
Ashish Jakhetiya, Department of Surgical Oncology, Dr BRA Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi 110029, India
Author contributions: Garg PK conceptualized the study; Garg PK and Sharma J searched the literature, analyzed the retrieved literature, and wrote the initial draft; Jakhetiya A, Goel A and Gaur MK provided critical inputs in literature search and analysis, and drafting the manuscript; all the authors read the final draft and approved it.
Conflict-of-interest statement: There is no conflict of interest associated with any of the author.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Dr. Pankaj Kumar Garg, Associate Professor, Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Dilshad Garden, Delhi 110095, India.
Telephone: +91-11-22592536 Fax: +91-11-22590495
Received: June 7, 2016
Peer-review started: June 11, 2016
First decision: July 29, 2016
Revised: August 23, 2016
Accepted: September 28, 2016
Article in press: September 28, 2016
Published online: October 21, 2016

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.