Advances in the management of esophageal cancer

Abstract

The management of clinical stage III and IVa esophageal cancer has evolved in the past 2 decades. Based on the Cross trial, neoadjuvant chemoradiation, followed by surgical resection has become standard. For medically inoperable, definitive chemoradiation is most commonly used. The standard radiation dose is 50.4 Gy although trials of doseescalation are ongoing. At the current time, there are no definitive biomarkers to predict response. Keywords:Esophageal cancer, Radiation therapy, Chemotherapy, Dose-escalation NONOPERATIVE THERAPY Radiation therapy aloneRadiation therapy alone is limited to palliation or for patients who are medically unable to tolerate chemotherapy. The 5-year survival rate for patients treated with conventional doses of radiation therapy alone is 0-10% [1-3]. In the radiation therapy alone arm of the RTOG 85-01 trial in which patients received 64 Gy at 2 Gy/day with conventional techniques, all patients were all dead of disease by 3 years [4,5] Dose intensification with brachytherapyBrachytherapy can be delivered by low or high dose rates and has previously been used as a boost following external beam radiation therapy or chemoradiation [7][8][9][10][11][12][13][14][15][16]. This technique is limited by the effective treatment distance. The primary isotope is 192Ir, which is usually prescribed to treat to a distance of 1 cm from the source. Therefore, as confirmed by pathologic analysis of treated specimens, any portion of the tumor which is >1 cm from the source will receive a suboptimal radiation dose [17].Retrospective and single institution trials suggest that there is no advantage of adding brachytherapy to external beam radiation. Chemoradiation plus brachytherapy was tested prospectively by the RTOG 92-07 trial. A total of 75 patients with cancers of the thoracic esophagus (92% squamous cell, 8% adenocarcinoma) received the RTOG 85-01 50 Gy chemoradiation regimen followed by a boost during cycle 3 of chemotherapy with either low dose rate or high dose rate intraluminal brachytherapy [22]. Due to low accrual the low dose rate option was discontinued and the analysis was limited to patients who received the high dose rate treatment. High dose rate brachytherapy was delivered in weekly fractions of 5 Gy during weeks 8, 9, and 10. Several patients developed fistulas and the fraction delivered at week 10 was discontinued. The complete response rate was 73%. With a median follow-up of only 11 months, local failure as the first site of failure was 27%. Acute toxicities were high. These included 58% grade 3, 26% grade 4, and 8% grade 5 (treatment-related death). The

Proceedings in oncology: Aren’t we back to the future?

“…In this issue Bruce Minsky prepared a comprehensive review about the advances in the management of esophageal carcinoma [1]. Faysal Dane outlined the importance of HER-2 targeted therapies on gastric carcinomas [2].…”