Esophageal squamous cell carcinoma (ESCC) is one of the commonest malignancies in China. Surgery is the main treatment for ESCC. However, the long-term survival is very poor by surgery alone. Perioperative multimodality treatment, including locally and systemically administrated, preoperatively and postoperatively, has been and will be the standard treatment in terms of improving long-term survival. Base on decades of practice and clinical trials, it is believed that preoperative treatment is better than postoperative treatment, and that chemotherapy plus radiotherapy preoperatively is better than either chemotherapy or radiotherapy alone. Therefore, preoperative radiochemotherapy followed by surgery is the standard treatment and future direction for locally advanced ESCC.
Chemotherapy, Adjuvant ; Combined Modality Therapy ; Esophageal Neoplasms ; surgery ; therapy ; Humans ; Neoadjuvant Therapy ; Perioperative Care ; Radiotherapy, Adjuvant

The prognosis of patients with locally advanced esophageal cancer treated by surgery alone is poor. The neoadjuvant chemoradiotherapy is considered to improve the long-term survival of patients with locally advanced esophageal cancer. The combination of neoadjuvant chemoradiotherapy and surgery has been recommended to be the standard treatment for the locally advanced esophageal cancer in China even in Europe and America countries. However, available evidence suggests that only those who had histopathologic response seemed to benefit the most from neoadjuvant chemotherapy while non-responders even had rather worse outcome compared to patients with surgery alone. Therefore, predictive markers of response to neoadjuvant chemoradiotherapy in locally advanced esophageal cancer are highly significant and needed. These markers would allow a tailored treatment to guide non-responders to alternative preoperative therapies and ultimately avoid ineffective, costly and seriously cytotoxic treatments. Results of most studies on biomarkers for predicting response to neoadjuvant chemoradiotherapy in esophageal cancer are promising. The potential utilization of biomarkers in clinical practice is urgently expected and needed, which plays an important role in guiding and improving the individualization of multimodality therapy in locally advanced esophageal cancer.
Biomarkers, Tumor ; Chemoradiotherapy ; Esophageal Neoplasms ; drug therapy ; radiotherapy ; surgery ; Humans ; Neoadjuvant Therapy ; methods ; Treatment Outcome

Most patients with esophageal cancer have advanced disease at presentation. The efficacy of surgical resection alone is often unsatisfactory in patients with stage III or more advanced cancer according to the seventh edition of UICC staging system for esophageal cancer. The systematic multidisciplinary treatment is important. Mounting evidence indicates that preoperative concurrent chemoradiotherapy is the most effective induction therapy to down-stage tumor and increase radical resection rate. For the esophageal squamous cell carcinoma patients with multi-stations and multi-fields lymph node metastasis, preoperative induction chemotherapy would be a viable option. For locally advanced cancers which have been surgically resected, postoperative adjuvant radiotherapy maybe helpful to improve local control for the insufficient surgical dissection. The role of adjuvant chemotherapy also needs further studies. Thoracic esophageal squamous cell carcinoma and lower esophageal adenocarcinoma which is common in western countries are different. We need more prospective clinical studies to establish our treatment modalities for esophageal cancer.
Carcinoma, Squamous Cell ; drug therapy ; radiotherapy ; surgery ; Chemotherapy, Adjuvant ; Combined Modality Therapy ; Esophageal Neoplasms ; drug therapy ; radiotherapy ; surgery ; Humans ; Prospective Studies ; Radiotherapy, Adjuvant

Esophageal cancer is usually detected in the advanced stage due to its anatomical characteristics. Recently, early esophageal cancers are detected more frequently with the nationwide screening of digestive tract cancer and development of new endoscopic technology in Korea. From the treatment view point, esophageal cancer can be categorized into early, locally advanced resectable, locally advanced unresectable, and metastatic esophageal cancer. Traditionally, surgery has been the mainstay of treatment for resectable esophageal cancer. However, endoscopic resection can be another therapeutic option in selected early esophageal cancer cases. Although most studies with preoperative chemoradiotherapy and subsequent surgery in locally advanced resectable cancer could not demonstrate definite survival benefit, many authorities prefer this multimodality approach to surgery alone. Best supportive care is always necessary for those with unresectable esophageal cancer, and palliation for dysphagia can be considered according to the patients' status. For the best management of esophageal cancer, the development of diagnostic method for more accurate staging should be followed.
Antineoplastic Combined Chemotherapy Protocols/therapeutic use ; Combined Modality Therapy ; Esophageal Neoplasms/radiotherapy/surgery/*therapy ; Esophagoscopy ; Humans ; Treatment Outcome

OBJECTIVETo analyze the relation between pathologic tumor response in preoperative radiotherapy and long-term survival in patients with esophageal carcinoma and the significance of radiosensitivity in the treatment of esophageal carcinoma.

METHODS176 esophageal cancer patients received preoperative radiotherapy and tumor resection from 1977 to 1989. The radio-response was classified into severe, moderate and mild according to the tumor pathologic response to radiotherapy. 191 patients treated by surgery alone served as control. The relation between radiation response of tumor and long-term survival and disease free survival was analyzed.

RESULTSThe 5-year survival rates of severe, moderate, mild and control groups were 60.7%, 46.4%, 21.1% and 38.8%. The survival was significantly improved in severe than moderate one (P = 0.029), moderate than mild group (P = 0.013) and severe than the control group (P = 0.000). It was only slightly improved in the moderate than control group (P = 0.295), but decreased in mild than the control group (P = 0.034). The 5-year disease-free survival (DFS) rates were 55.7%, 40.7%, 18.7% and 33.3% in severe, moderate, mild and control groups. The DFS was significantly improved in severe than moderate group (P = 0.029), moderate than mild group (P = 0.018), severe than the control group (P = 0.000 4). It was only slightly improved in moderate than the control group (P = 0.23), but decreased in the mild than the control group (P = 0.096). In the severe group, the proportion of stage T4, N1 lesion, TNM stage I-II and number of radical resection were 9.8%, 18%, 90.2%, and 90.2%. In the moderate group, they were 20.3%, 15.9%, 79.7% and 82.6%. In the mild group, they were 42.2%, 37.8%, 53.3% and 46.7%. In the control group, they were 50.3%, 40.8%, 37.7% and 77.5%. The rates of downstaging and surgical resection were improved only in severe and moderate groups (P < 0.01).

CONCLUSIONThe fact that only patients in whom severe radiation response are observed would appreciably benefit from preoperative radiotherapy whereas the others do not, illustrates that there might be no benefit of radiotherapy for radioresistant esophageal carcinoma. Radiosensitivity measurement before preoperative radiotherapy would be valuable for individualized treatment.

Adult ; Aged ; Combined Modality Therapy ; Esophageal Neoplasms ; mortality ; pathology ; radiotherapy ; surgery ; Female ; Humans ; Male ; Middle Aged ; Prognosis

Adenocarcinoma ; classification ; pathology ; surgery ; therapy ; Cardia ; Chemotherapy, Adjuvant ; Esophageal Neoplasms ; classification ; pathology ; surgery ; therapy ; Esophagectomy ; methods ; Esophagogastric Junction ; surgery ; Gastrectomy ; methods ; Humans ; Neoplasm Staging ; Radiotherapy, Adjuvant ; Stomach Neoplasms ; classification ; pathology ; surgery ; therapy

Conventional treatment of esophageal cancer with surgery or radiation alone has afforded few long-term survivors. In order to improve outcome and determine the efficacy of a combined modality approach, this prospective study was performed. Between May 1993 and August 1994, 27 patients with loco-regional squamous cell carcinoma of the esophagus were treated with 2 courses of combined fluorouracil(1000mg per square meter of body-surface area daily for 5 days) and cisplatin(60mg per square meter on the first day)(D1 and D29) plus 48Gy of radiation therapy(RT) over 4 weeks. A transhiatal esophagectomy was planned 3-4 weeks after chemoradiotherapy. Twenty-seven patients completed a full course of therapy. Clinical response was evaluable in 26 patients: 22 patients showed improvement and relief from dysphagia, 2 patients stable disease, and 2 patients progression. One patient died of sepsis 1 week after completion of chemoradiotherapy and was excluded from the analysis. Ten patients underwent operation after chemoradiation. Of them, 5 showed complete histologic response. One of the complete responders died of recurred disease 8.5months after operation, the other 2 patients died of sudden death, and sepsis from wound deheiscence 7 days after operation, respectively. Nine patients refused operation because of excellent relief of their dysphagia and 6 patients were denied because of disease progression(2), fear of operations(2), old age and family member's disapprovement(1), and underlying liver cirrhosis(1). The last one patient was awaiting for operation. Of 13 patients who refused or denied operation, 6 patients finished further chemotherapy and radiatherapy(external radiation 1200 CGy+intracavitary radiation 900 CGy, 2 cycles of 5FU+cisplatin). This intensive preoperative chemoradiotherapy is feasible, and allows for a high rate of resectability and a high rate of complete pathologic response in a locoregional esophageal cancer. Toxicity is considerable but manageable. This study warrants further investigation.
Adult ; Aged ; Antineoplastic Combined Chemotherapy Protocols/adverse effects/therapeutic use ; Carcinoma, Squamous Cell/radiotherapy/surgery/*therapy ; Cisplatin/administration & dosage ; Combined Modality Therapy ; Esophageal Neoplasms/radiotherapy/surgery/*therapy ; Female ; Fluorouracil/administration & dosage ; Human ; Male ; Middle Age ; *Preoperative Care ; Prospective Studies

BACKGROUND/AIMS: This study was designed to compare the survival rates between patients with localized esophgeal cancer who were treated with concurrent chemoradiation therapy without surgery and patients who were treated with concurrent chemoradiation therapy including surgery. METHODS: Eighty-eight patients from January 1997 to December 2005 with locally advaned resectable esophageal cancer were selected and retrospectively analyzed. Survival period was defined as the time to death from the date of diagnosis or mid-monitor period of December 2005. Sixty-one patients were treated with chemoradiation therapy alone while twenty-seven patients were treated with chemoradiation therapy in addition to surgery as for curative intention. As for radiation therapy, 5,000-5,500 cGY was used. 5-Fluouracil and cisplatin were used for chemotherapy. The primary end point was overall survival time. The secondary end point was overall progression free survival time. RESULTS: There was no significant difference in tissue type, location and clinical staging, but the median age was significantly younger in the group treated with surgery (63.4 years) than the group treated without surgery (68.8 years). Median period analyzed was 17.3 months. Five year survival rate for the group with chemoradiation alone was 7.4% and 4% for the group with surgery. The median survival rate was 11+/-3 months for the group with chemoradiation alone and 10+/-6 months for the group with surgery, in which there was no statistical difference (p=0.697). CONCLUSIONS: There was no significant increase in survival rate in patients who were treated by chemoradiation with surgery compared with chemoradiation alone. Further analysis in terms of prospective study is needed.
Aged ; Aged, 80 and over ; Antineoplastic Agents/therapeutic use ; Combined Modality Therapy ; Data Interpretation, Statistical ; Esophageal Neoplasms/radiotherapy/surgery/*therapy ; Female ; Humans ; Male ; Middle Aged ; Neoplasm Staging ; Survival Rate

OBJECTIVETo evaluate the effect of combined chemoradiotherapy followed by surgery for patients with esophageal carcinoma.

METHODSNinety-seven patients with stage II or III esophageal carcinoma without contraindication against operation and chemoradiotherapy, were randomly divided into two groups: combined group (Group A) 48 and control group (Group B) 49. Patients in group A were given neoadjuvant treatment consisted of chemotherapy with 5-fluorouracil and cisplatin for 2 cycles and radiotherapy of DT36 Gy/12 f/17 d. Three weeks later, operation was performed. Patients in group B were given operation alone. Survival rate was calculated with Kaplan-Meier method. Chi and Log-rank test was used to assess the difference between the two groups.

RESULTSThe radical resectability of group A and group B were 85.4% and 65.3% (P = 0.018 1). The lymph node metastasis rate of the two groups were 21.7% and 45.7% (P = 0.019 4). The T stage of group A was significantly lowered (P = 0.003 6). The local and regional recurrence rate of two groups were 34.8% and 58.7% (P = 0.023 6), while there was no significant difference in operative complications between the two groups. Significant improvement in the long-term survival rate was observed in group A, especially in patients who achieved partial and complete response with high 5-year survival rate of 56.5%.

CONCLUSIONPreoperative neoadjuvant chemoradiotherapy is able to reduce the tumor and tumor stage, lower the lymph node metastasis rate and local or regional recurrence rate, also it can improve radical resectability and long-term survival without increasing the operative complications.

Adenocarcinoma ; drug therapy ; radiotherapy ; surgery ; Adult ; Aged ; Antineoplastic Combined Chemotherapy Protocols ; administration & dosage ; therapeutic use ; Carcinoma, Squamous Cell ; drug therapy ; radiotherapy ; surgery ; Chemotherapy, Adjuvant ; Cisplatin ; administration & dosage ; Esophageal Neoplasms ; drug therapy ; radiotherapy ; surgery ; Esophagectomy ; Female ; Fluorouracil ; administration & dosage ; Humans ; Lymphatic Metastasis ; Male ; Middle Aged ; Neoplasm Recurrence, Local ; Neoplasm Staging ; Particle Accelerators ; Prospective Studies ; Radiotherapy, Adjuvant ; Survival Rate

OBJECTIVETo evaluate the clinical value of prophylactic radiotherapy for esophageal carcinoma after curative operation.

METHODS495 esophageal squamous cell cancer patients who had undergone radical resection were randomized by the envelope method into a surgery alone group (S, 275) and a surgery plus radiotherapy group (S + R, 220). Radiation treatment was started 3 - 4 weeks after operation. The portals encompassed the whole mediastinum and bilateral supraclavicular areas. A mid-plane dose of 50 approximately 60 Gy in 20 approximately 30 fractions over 5 approximately 6 weeks was delivered.

RESULTS1. Survival rate: the overall 5-year survival rate was 39.4%. Those of S alone and S + R groups were 37.1% and 41.3% (P = 0.447 4). The 5-year survival rate for Stage III patients were 13.1% in S alone group and 35.1% in R + S group (P = 0.002 7), 2. Pattern of failure: The incidence of local recurrence intra-thoracic lymph node metastasis, anastomotic recurrence and extra-thoracic lymph node metastasis in S + R group (16.2%, 0.5% and 3.1%) were lower than those (25.9%, 5.8% and 13.2%) (P < 0.05) in S alone group and 3.

COMPLICATIONSthe anastomotic stricture frequencies were similar in the two groups (S 1.8%; S + R 4.1%).

CONCLUSION1. Prophylactic radiotherapy is able to improve the survival rate of stage III patients treated by radical resection, 2. Postoperative radiotherapy is able to reduce the incidence of failure by recurrence in the intra-thoracic lymph nodes and anastomotic recurrence to where radiation therapy had been given, 3. Postoperative radiotherapy does not increase the incidence of anastomotic stricture.

Adult ; Aged ; Carcinoma, Squamous Cell ; mortality ; radiotherapy ; secondary ; surgery ; Combined Modality Therapy ; Esophageal Neoplasms ; mortality ; pathology ; radiotherapy ; surgery ; Female ; Humans ; Lymphatic Metastasis ; Male ; Middle Aged ; Postoperative Care ; Survival Rate