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Gastrointestinal Cancer Current Standards and New Trends in Oesophageal Cancer Florian Lordick Director, Third Medical Department (Haematology and Oncology), Klinikum Braunschweig, Germany Abstract Oesophageal squamous cell cancer has a constant or even decreasing incidence rate in many regions in Europe, while oesophageal adenocarcinoma and oesophagogastric junction (OGJ) cancer have shown an increasing incidence over the past three decades. If diagnosed at an early stage (stage I), which is rarely the case, these cancers have a good prognosis. Endoscopic resection can then be recommended in selected cases where the submucosal layer is not reached. In these cases, surgical resection is regarded as the standard of care. In contrast, in stages II and III, the prognosis is more critical. Local relapses and distant metastases occur frequently during post-surgical follow-up, leading to long-term survival being as poor as 20–30 %. For locally advanced tumours, multimodal treatment has been established as the new standard of care. Neoadjuvant chemotherapy or chemoradiation have proven efficacy in adenocarcinoma of the oesophagus. Neoadjuvant chemoradiation (followed by surgery) and definitive chemoradiation are two proven and equivalent options with comparable outcomes in oesophageal squamous cell cancer. In metastatic disease, chemotherapy on the basis of cisplatin and 5-fluorouracil can be offered in order to achieve better symptom control, although prolongation of survival has not formally been proven due to a lack of randomised controlled clinical studies. Keywords Oesophageal cancer, oesophagogastric junction, chemotherapy, chemoradiotherapy, neoadjuvant, peri-operative, targeted, antibody, positron emission tomography Disclosure: The author has no conflicts of interest to declare. Received: 26 January 2012 Accepted: 6 February 2012 Citation: European Oncology & Haematology, 2012;8(2):105–6 Correspondence: Florian Lordick, Director, Third Medical Department (Haematology and Oncology), Klinikum Braunschweig, Celler Strasse 38, 38114 Braunschweig, Germany. E: medklinik3@klinikum-braunschweig.de Oesophageal adenocarcinoma and oesophagogastric junction (OGJ) cancer have shown an increasing incidence over the past three decades in many European countries and other regions of the world with a Western lifestyle, indicating strong environmental influences on pathogenesis. Oesophageal adenocarcinoma and OGJ cancer are among the most common cancers in Europe and other parts of the world. In many countries, they are found more frequently than oesophageal squamous cell cancer. 1 If diagnosed at an early stage (stage I), which is rarely the case in Europe, oesophageal adenocarcinoma and OGJ cancer have a relatively good prognosis. Endoscopic resection can be recommended in selected cases where the infiltration does not go beyond the mucosal layer. Alternatively, surgical resection leads to a cure in the vast majority of patients in early stages. In contrast, in stages II and III, the prognosis is more critical. Local relapses and distant metastases occur frequently in the post-surgical follow-up. The five-year survival rate used to be as poor as 20–30 %. 1 Using the increasing opportunities of multimodal treatment and the experience gained at specialised centres, the outcome of oesophageal cancer can be significantly improved. In Western societies, oesophageal squamous cell cancer is generally associated with a more dismal prognosis than adenocarcinoma. 2 Treatment Strategies Randomised studies have shown that neoadjuvant and peri-operative chemotherapy lead to an improved outcome in patients with adenocarcinoma of the oesophagus and OGJ. On the basis of current © TOUCH BRIEFINGS 2012 meta-analyses, patients are now treated with pre- and peri-operative chemotherapy. In some centres, neoadjuvant concurrent chemoradiation is the preferred approach. 3 Combined chemoradiation has not shown superior outcomes when compared with neoadjuvant chemotherapy alone 3 and, according to some studies, it may lead to increased morbidity and increased peri-operative mortality. This is why many European centres regard peri-operative chemotherapy without radiation as their standard approach. In the recently published European Society for Medical Oncology (ESMO) guidelines, peri-operative chemotherapy is recommended in patients with T3/T4 oesophageal and OGJ cancer. Neoadjuvant chemoradiation is regarded as an alternative approach. 4 In locally advanced squamous cell cancer of the oesophagus, pre-operative chemoradiation has shown some benefit. 3 It is a matter of debate when oesophageal resection should be performed and in which particular subgroups of patients definitive chemoradiation may lead to satisfying long-term outcomes. Comparative studies have shown comparable survival. 5 Functional imaging and molecular prognostic markers may support decision-making in the future. Currently, it is recommended that patients presenting with resectable squamous cell carcinoma and without limiting cardiorespiratory, hepatic and other co-morbidities should be offered oesophagectomy. Neoadjuvant concurrent chemoradiation can be recommended in tumour categories ≥T3. 3,4 The currently suggested treatment algorithm for localised oesophageal cancer is illustrated in Figure 1. 105