Surgery, radiotherapy, and chemotherapy for esophageal cancer

Operative resection, the standard of care in the radical management of locoregional esophageal cancer, is a major surgical procedure, with a clear learning curve. It should be performed by experienced surgeons with a sufficient annual volume of procedures to maintain competence. Within specialized units esophagectomy can be safely offered to appropriately selected patients of all age groups. So far, the choice of operative approach (transhiatal, limited transthoracic, extended transthoracic) still cannot be based on randomized data with sufficient discriminating power. To date, the role of preoperative neoadjuvant therapy has not been clearly defined. A meta-analysis of five randomized trials did not confirm a substantial benefit for preoperative radiotherapy. A large randomized trial failed to show any benefit for preoperative chemotherapy. Improving systemic therapy, probably in combination with radiotherapy, remains a high priority for the coming years. The recent identification of new, highly active, chemotherapeutic agents shows promising, albeit preliminary, results.