Current therapeutic approaches to localized carcinoma of the esophagus and gastroesophageal junction

Mariela A Blum, Akihiro Suzuki, Takashi Taketa and Jaffer A Ajani

Esophageal cancer is a deadly disease and only 40–50% of patients have potentially resectable cancer at diagnosis. Accurate staging and multidisciplinary evaluation are essential before any therapy is started. In locally advanced disease, primary surgery leads to poor long-term survival; however, an R0 resection is essential for cure. Clinical trials investigating multimodality treatments have led to improved outcomes and more options. However, the treatment of localized esophageal cancer based on two major histologic subtypes is a subject of debate. Squamous cell carcinoma (SCC) and esophageal adenocarcinoma (EAC) are included in most of the trials but it may take time to propose different approaches.

In general for LEC, preoperative chemotherapy is preferred in some parts of Europe for EAC; however, in the USA, preoperative chemoradiation has been popular and supported by level 1 evidence. For patients who are unsuitable for surgery, definitive chemoradiation is appropriate. For SCC of the cervical and upper thoracic regions, definitive chemoradiation and salvage surgery are appropriate. Preoperative chemoradiation is recommended for EAC and lower thoracic SCC. Some patients who undergo primary surgical resection may benefit from adjuvant chemoradiation. Overall, we recommend trimodality approach for all trimodality-eligible patients. Primary surgery is advocated for T1bN0 stage and endoscopic therapy would be

appropriate for T1a or TIS stage. This article briefly reviews these aspects of LEC.