Treatment and clinical outcome of clinical T4 esophageal cancer: A systematic review

Abstract

Background Survival of patients with cT4 esophageal cancer is dismal. Although the optimal treatment strategy remains to be established, two treatment options are available for cT4 esophageal cancers: definitive chemoradiation (dCRT) and induction treatment followed by conversion surgery (CS). However, little is known concerning the differences in clinical outcome between patients with T4 esophageal tumors treated with dCRT and those eventually treated with CS. Methods A systematic search of the scientific literature on PubMed/MEDLINE was carried out using the keywords “T4 esophageal cancer,” “invading (involving) adjacent organ,” “definitive chemoradiation,” “induction therapy,” “salvage surgery,” and “conversion surgery,” obtaining 28 reports published up to July 2018. Results/Conclusion We found that CS was superior to dCRT with respect to local disease control and short‐term survival; however, CS was associated with relatively higher perioperative mortality and morbidity. Alternatively, although dCRT might often cause fistula formation, a clinical complete response to dCRT is likely to lead to a better prognosis. Recent advances in chemotherapeutic agents have led to triple induction chemotherapy, with docetaxel, cisplatin, and 5‐fluorouracil (DCF), which has shown promise as an initial induction treatment for cT4 esophageal cancer. Indeed, this regimen could control both local and systemic disease, which enables curative resection without preoperative CRT. Moreover, some appropriate changes in perioperative management and intensive systemic chemotherapy might enhance patient outcome. Randomized controlled trials with a large sample size are needed to establish the standard treatment for cT4 esophageal cancer.

Salvage Robot-Assisted Minimally Invasive Esophagectomy (RAMIE) for T4b Esophageal Cancer After Definitive Chemoradiotherapy

“…Patients with esophageal cancer that invades adjacent structures such as the trachea or aorta (cT4b) often are precluded from surgery and treated with definitive chemoradiotherapy (dCRT). 1 dCRT alone results in high locoregional failure rates of up to 50% and low 3-year survival rates of 20% to 25%. 2 – 7 …”

Chemotherapy alone versus definitive concurrent chemoradiotherapy for cT4b esophageal squamous cell carcinoma: a population-based study

“…However, our study should also be interpreted with caution given its nonrandomized nature, and RCTs are needed for confirmation. However, no RCTs were included in a recent relevant systematic review [ 30 ]. When we further searched the trial registry ( https://clinicaltrials.gov/ ) in Dec 2020, we did not find relevant RCTs.…”

Long-term results of definitive chemoradiotherapy for unresectable locally advanced esophageal squamous cell carcinoma

“…Regarding the long-term prognosis of definitive CRT for unresectable LA-ESCC, few prospective and retrospective studies that have evaluated with a sufficient number of patients and sufficient follow-up period [ 10 , 14–15 ]. Fujita et al.…”

“…Currently, the standard of care for unresectable LA-ESCC is definitive CRT based on the evidence for resectable LA-ESCC described above as well as the results of several clinical trials for unresectable LA-ESCC [ 7–9 ]. However, most prospective and retrospective studies on unresectable LA-ESCC have evaluated survival and safety over a relatively short term of 2–3 years, and few studies have evaluated the long-term outcomes over a sufficient follow-up period [ 10 ]. Recently, a favorable outcome of multidisciplinary treatment with induction chemotherapy combined with CRT and conversion surgery has been reported and is expected to improve the prognosis of unresectable LA-ESCC [ 11 , 12 ].…”