Multi-disciplinary management of esophageal carcinoma: Current practices and future directions

Abstract

Esophageal cancer in one of the most malignant and hard-to-treat cancers. Esophageal squamous carcinoma (ESCC) is most common in Asian countries, whereas adenocarcinoma at the esophago-gastric junction (EGJ AC) is more prevalent in the Western countries. Due to differences in both genetic background and response to chemotherapy and radiotherapy, both histologic subtypes need different paradigms of management. Since the landmark CROSS study has demonstrated the superior survival benefit of tri-modality including neoadjuvant chemoradiotherapy prior to esophagectomy, the tri-modality becomes the standard of care; however, it is suitable for a highly-selected patient. Tri-modality should be offered for every ESCC patient, if a patient is fit for surgery with adequate cardiopulmonary reserve, regardless of ages. Definitive chemoradiotherapy remains the best option for a patient who is not a surgical candidate or declines surgery. On the contrary, owing to doubtful benefits of radiotherapy with potentially more toxicities related to radiotherapy in EGJ AC, either neoadjuvant chemotherapy or peri-operative chemotherapy would be more preferable in an EGJ AC patient. In case of very locally advanced disease (cT4b), the proper management is more challenging. Even though, palliative care is the safe option, multi-modality therapy with curative intent like neoadjuvant chemotherapy with conversion surgery may be worthwhile; however, it should be suggested on case-by-case basis. • Esophageal squamous cell carcinoma (ESCC) and adenocarcinoma (EAC) are different diseases that need specific paradigm of management in particular. • In case of fit patients with locally-advanced ESCC, the tri-modality treatment (TMT) including neo-adjuvant chemo-radiotherapy (nCCRT) followed by esophagectomy is the treatment of choice, on the other hand, in case of EAC, neoadjuvant chemotherapy (nCT) followed by surgery is the optimal treatment. Enthusiastically, surgery can be safely omitted, if ESCC patients can be proven to get pathological complete response (pCR) after nCCRT. • Definitive chemo-radiotherapy (dCCRT) has still been the possible option for unfit patients with ESCC. Innovative radiotherapy techniques such as proton therapy may further improve the outcomes. • Nivolumab is right now a standard of care as the adjuvant treatment for those who have residual disease after TMT; however, we still lack of validated biomarkers of clinical benefits and OS data. • Elderly patients are the vulnerable group requiring clinical judgement on case-by-case basis. We have solid evidences to demonstrate that age alone is not a determining factor for treatment with curative intent. • Non metastatic cT4b disease is almost fatal. No consensus on most suitable management is developed specifically.

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