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World J Gastrointest Oncol. Aug 15, 2014; 6(8): 263-274
Published online Aug 15, 2014. doi: 10.4251/wjgo.v6.i8.263
Esophageal cancer management controversies: Radiation oncology point of view
Patricia Tai, Edward Yu
Patricia Tai, Department of Oncology, Division of Radiation Oncology, Allan Blair Cancer Center, University of Saskatchewan, Regina, SK S4T 7T1, Canada
Edward Yu, Department of Oncology, Division of Radiation Oncology, Western University, London, ON N6A 4L6, Canada
Author contributions: All authors designed, wrote and approved the final version of manuscript.
Correspondence to: Dr. Edward Yu, Department of Oncology, Division of Radiation Oncology, Western University, 790 Commissioner Road East, London, ON N6A 4L6, Canada. edward.yu@lhsc.on.ca
Telephone: +1-519-6858650 Fax: +1-519-6858627
Received: November 28, 2013
Revised: March 21, 2014
Accepted: May 31, 2014
Published online: August 15, 2014
Abstract

Esophageal cancer treatment has evolved from single modality to trimodality therapy. There are some controversies of the role, target volumes and dose of radiotherapy (RT) in the literature over decades. The present review focuses primarily on RT as part of the treatment modalities, and highlight on the RT volume and its dose in the management of esophageal cancer. The randomized adjuvant chemoradiation (CRT) trial, intergroup trial (INT 0116) enrolled 559 patients with resected adenocarcinoma of the stomach or gastroesophageal junction. They were randomly assigned to surgery plus postoperative CRT or surgery alone. Analyses show robust treatment benefit of adjuvant CRT in most subsets for postoperative CRT. The Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) used a lower RT dose of 41.4 Gray in 23 fractions with newer chemotherapeutic agents carboplatin and paclitaxel to achieve an excellent result. Target volume of external beam radiation therapy and its coverage have been in debate for years among radiation oncologists. Pre-operative and post-operative target volumes are designed to optimize for disease control. Esophageal brachytherapy is effective in the palliation of dysphagia, but should not be given concomitantly with chemotherapy or external beam RT. The role of brachytherapy in multimodality management requires further investigation. On-going studies of multidisciplinary treatment in locally advanced cancer include: ZTOG1201 trial (a phase II trial of neoadjuvant and adjuvant CRT) and QUINTETT (a phase III trial of neoadjuvant vs adjuvant therapy with quality of life analysis). These trials hopefully will shed more light on the future management of esophageal cancer.

Keywords: Radiotherapy, Chemotherapy, Esophagus, Cancer, Treatment

Core tip: Esophageal cancer treatment has evolved from single modality to trimodality therapy. There are some controversies of the role, target volumes and dose of radiotherapy (RT) in the literature over decades. Esophageal brachytherapy is effective in the palliation of dysphagia, but should not be given concomitantly with chemo or external beam RT. On-going studies include: ZTOG1201 trial (a phase II trial of neoadjuvant and adjuvant chemoradiation) and QUINTETT (a phase III trial of neoadjuvant vs adjuvant therapy). These trials hopefully will shed more light on the future management of esophageal cancer.