Treatment of thoracic esophageal carcinoma invading adjacent structures

Abstract

T4 esophageal cancer is defined as the tumor invading adjacent structures, using tumor-node-metastasis (TNM) staging. For clinically T4 thoracic esophageal carcinoma, multimodality therapy, that is, neoadjuvant chemoradiotherapy (CRT) followed by surgery or definitive CRT, has generally been performed. However, the prognosis of patients with these tumors remains poor. Another strategy is needed to achieve curative treatment. In the present article, the treatment strategies employed to date are reviewed. Furthermore, the strategies for these malignancies are reassessed, based on our experiences. R1/2 and R0 resections are regarded as those with residual and no tumor after surgery. The present data show that patients who underwent R1/2 resection after neoadjuvant CRT experienced little survival benefit, while complete response (CR) cases after definitive CRT had comparatively better results. Therefore, curative surgery should not be attempted without down-staging, and definitive CRT should be the initial treatment. Then surgery is indicated for the eradication of residual cancer cells. Close surveillance is essential for early detection of relapse even after CR, because the operation will gradually become increasingly difficult due to post-CRT fibrosis. In conclusion, multimodality therapy consists of definitive CRT followed by R0 resection, which can be the treatment of choice for T4 esophageal carcinoma. These challenging treatments have the potential to constitute the most effective therapeutic strategy. (Cancer Sci 2007; 98: 937-942) T he incidence of stage T4, in which the tumor invades adjacent structures, is reported to be 8-30% among thoracic esophageal carcinomas.(1-9) A standard treatment for these diseases has not, however, been established. The variety of treatments currently available include surgery alone,(1,2) chemotherapy followed by surgery, (10) chemoradiotherapy (CRT) followed by surgery, (3)(4)(5)(6)(11)(12)(13)(14)(15) and definitive CRT. (6,7,(16)(17)(18)(19)(20) The extremely poor prognosis of patients with these T4 tumors is well known, irrespective of the treatments employed.(1-21) Therefore, curative treatment for T4 esophageal carcinoma remains an elusive challenge.The accurate diagnosis of T4 and the indications for combined resection of the invaded organs and additional surgery after definitive CRT are unresolved issues. The most serious problem is which treatment should be selected first. It is difficult to decide whether definitive or neoadjuvant CRT should be given initially to a patient with a potential T4 tumor. In the present article, these problems regarding the treatment of T4 thoracic esophageal carcinoma are reviewed. Furthermore, the strategy for managing these diseases is reassessed, based on results obtained by the authors' institute hospital. DiagnosisDepth of invasion is usually diagnosed using computed tomography (CT) (1)(2)(3)(4)(5)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21) and/or endoscopic ultrasonography (EUS).(1,9-11, [13][14][15][16][17][18]20,21) The invade...

Involved-Field Irradiation in Definitive Chemoradiotherapy for T4 Squamous Cell Carcinoma of the Esophagus

“…Median duration of pfs in patients with no response to treatment was just 2 months, and median os was 5 months. Seto et al 13 similarly examined prognosis according to the response to chemoradiotherapy in T4 patients and reported 1-, 3-, and 5-year survival rates of 83%, 33%, and 33% respectively for patients experiencing a cr, compared with 23%, 0%, and 0% for patients not experiencing a cr.…”

Treatment of T4 Esophageal Cancer. Definitive Chemo-Radiotherapy vs Chemo-Radiotherapy Followed by Surgery

“…With respect to late toxicities caused by D-CRT, although there are only two studies with relevant data, 10,19) Keneko et al 19) reported no serious late toxicity (grade 3 or higher) in their patients. Seto et al 10) followed nine patients who survived more than 1 year from the initiation of D-CRT and reported grade 2 pericardial effusion and radiation pneumonitis in 4 and 2 patients, respectively, while no late toxicity-related deaths were noted.…”

“…Seven 10,11,[18][19][20][21][22] out of 8 studies used 5-FU plus CDDP; at standard-doses (5-FU 300-700 mg/m 2 , CDDP 40-60 mg/m 2 ) in 4 studies, 10,18,19,21) low-dose CRT (5-FU 200-500 mg/m 2 , CDDP 3-10 mg/m 2 ) in two studies, 11,22) and both in one study. 20) Recently, Font et al 17) used weekly docetaxel regimen (20 mg/m 2 ).…”

“…8) Previous studies reported the effectiveness of concurrent chemo-radiotherapy (CRT) using this regimen in advanced esophageal cancer including T4 tumors. 9) Thus, two modalities are currently in use for the treatment of esophageal tumors 10,11) ; chemo-radiotherapy followed by surgery (CRT-S) [10][11][12][13][14][15][16] and definitive chemo-radiotherapy (D-CRT). [17][18][19][20][21][22] To the best of our knowledge, there is little or no information on the differences in clinical outcome of patients with T4 esophageal tumors who undergo D-CRT and those who receive CRT-S.…”

Comparison of conventional magnetic resonance imaging, cine-magnetic resonance imaging, and operation findings in invasion assessment of esophageal cancer

“…[16] The incidence of Stage T 4 , in which the tumor invades the adjacent structures, is reported as 8 to 30% among thoracic esophageal carcinomas. [17] Initially, the surgical treatment of patient with T 4 invasion for thorax would negatively affect the treatment process. The resection may be inadequate or accepted as inoperable and, then, neoadjuvant chemoradiotherapy decision can be made in these cases.…”