Staging and treatment of advanced esophageal cancer

To evaluate the recent developments in treatment of advanced esophageal cancer since January 2004.

Today's stage-adjusted treatment of advanced esophageal cancers requires a meticulous diagnostic work-up. The use of standard staging tools (endoscopy, endoscopic ultrasound, computed tomography) is increasingly supplemented with additional use of positron emission tomography with fluoro-desoxyglucose. Positron emission tomography with fluoro-desoxyglucose improves detection of systemic metastases, but assessment of locoregional lymph node metastases remains poor.Multimodal (especially neoadjuvant) strategies have gained far-reaching impact on advanced esophageal cancer treatment: A recent meta-analysis of randomized trials suggests a survival benefit at 3 years with preoperative radio-chemotherapy compared with surgery alone. Patients who respond to neoadjuvant treatment appear to benefit most from subsequent surgical resection. This makes response evaluation and prediction most desirable. Positron emission tomography with fluoro-desoxyglucose appears to provide reliable information on response as early as 14 days after initiation of treatment. Several studies have contributed to controversies regarding surgical technique (e.g. extent of lymphadenectomy, shape of gastric tube, location of anastomosis). Surgical complications have been directly correlated with long-term prognosis. In patients with systemic metastases, all therapeutic attempts remain palliative. In a multicenter trail, investigating the best palliation of dysphagia, brachytherapy was found superior over placement of self-expanding metal stents.

Positron emission tomography with fluoro-desoxyglucose is established as an additional staging tool and appears useful for response prediction during multimodal treatment. Brachytherapy should be considered as an alternative to stent placement for palliation of dysphagia.