Curative management of adenocarcinoma of the oesophagus--pro multimodal approach

The incidence rates of adenocarcinoma (AC) of the oesophagus were reported to increase rapidly in the Western Countries, especially within white males. Due to the late appearance of tumour specific symptomes, most of the carcinomas are diagnosed at advanced stages. Because of the majority of the patients presenting with lymph node metastases even in localized disease, the long term results with surgery alone are disappointing. Overall less than 35% can be cured and three year survival rates (3-YSR) rarely exceed 25% in patients with locally advanced tumours (T3/4N0-1M0). For these reasons multimodal approaches have been investigated recently. Preoperative chemoradiation seems to be most promising in improving the curative power of the treatment. Beside a couple of phase II studies, 2 phase III trials proved superiority of multimodal treatment compared with surgery alone in localized AC (1,2) by increasing 3-YSR from about 10% to 30%. These trials were critisized because of incomplete tumour staging and a possible stratification bias. However, recent phase II studies from the US and from our own group (3,4) confirmed the role of preoperative chemoradiation also in properly staged (including endoscopic ultrasound) locally advanced AC. Both trials showed complete resection rates of 90% and based on very high local tumour control rates of above 90% long term survival reached about 40% in these high risk patients. These impressive data were injured by perioperative mortality rates of 15%, which were obviously increased by the preoperative treatment. Thus, preoperative chemoradiotherapy is very likely to increase cure rates in patients with AC of the oesophagus. To prove this, well designed phase III trials are warranted.