management

Last edited 11/2021

Management of oesophageal carcinoma requires a multi-disciplinary team comprising of experienced clinicians representing surgery, oncology, radiology, pathology, specialist nurses, dieticians and specialists from other fields if required (1).

Surgery, chemotherapy, radiotherapy, a combination of the three or palliation may be used to manage the condition.

  • a fitness assessment should be carried out in patients who are considered for surgery or chemo-radiotherapy e.g. - pulmonary function test, ECG, echocardiogram, cardio-pulmonary exercise testing
  • treatment with a curative intent is undertaken for locally advanced oesophageal carcinoma without signs of distant metastasis while advanced (metastatic or disseminated) and recurrent disease are treated with palliative intent (1,2)

Treatment modalities for the management of oesophageal carcinoma include:

  • surgical treatment
    • is the main option for curative treatment
    • can be used alone or as a part of a multimodal approach
    • open oesophagectomy
      • options for resection of oesophageal carcinoma include
        • transhiatal oesophagectomy - through an abdominal and neck incision, without opening the thoracic wall
        • transthoracic oesophagectomy - can be
          • Ivor Lewis oesophagectomy (also called Lewis-Tanner oesophagectomy) abdominal and right thoracic approach
          • three-incision modified McKeown oesophagectomy - involves laparotomy, right thoracotomy, and neck anastomosis

    • choice of the method will depend on factors such as location of the tumour, access to lymph nodes, preference of surgeon
      • NICE suggest (4):
        • radical treatment for T1N0 oesophageal cancer
          • endoscopic mucosal resection should be offered for staging for people with suspected T1 oesophageal cancer
          • endoscopic eradication should be offered of remaining Barrett's mucosa for people with T1aN0 oesophageal cancer
        • if T1bN0 squamous cell carcinoma of the oesophagus offer the choice of:
          • definitive chemoradiotherapy or surgical resection
        • Surgical treatment of oesophageal cancer
          • an open or minimally invasive (including hybrid) oesophagectomy should be considered for surgical treatment of oesophageal cancer
        • squamous cell carcinoma of the oesophagus
          • offer people with resectable non-metastatic squamous cell carcinoma of the oesophagus the choice of:
            • radical chemoradiotherapy or
            • chemoradiotherapy before surgical resection
    • lymph node dissection
      • extent of the lymph node removal is controversial
      • three-field lymphadenectomy in the abdomen, chest, and neck (with dissection of nodes along the recurrent nerves)- mainly carried out in Japan where squamous cell carcinoma predominates
      • two-field lymphadenectomy in the abdomen and chest - more common in Europe and the USA
      • NICE suggest (4):
          • lymph node dissection in oesophageal and gastric cancer
            • when performing a curative gastrectomy for people with gastric cancer, consider a D2 lymph node dissection
            • when performing a curative oesophagectomy for people with oesophageal cancer, consider two-field lymph node dissection
          • localised oesophageal and gastro-oesophageal junctional adenocarcinoma
            • if localised oesophageal and gastro-oesophageal junctional adenocarcinoma (excluding T1N0 tumours) who are going to have surgical resection, offer a choice of:
              • chemotherapy, before or
              • before and after surgery or
              • chemoradiotherapy, before surgery
    • minimally invasive oesophagectomy
      • with the aim of decreasing the morbidity and mortality of open oesophagectomy , a combination of laparoscopic and thoracoscopic approach is used for the procedure  

  • neo-adjuvant chemotherapy
    • main aim is to improve the results of surgery by shrinking  the tumour prior to surgery, down staging the disease and treating occult metastatic disease
    • five year survival with
      • surgery alone - 17%
      • neo-adjuvant chemotherapy - 23%
    • is the standard of care for operable for mid or distal oesophageal (including gastro-oesophageal junction ) carcinomas

  • neo-adjuvant chemo-radiotherapy (CRT)
    • commonly used in the USA for locally advanced oesophageal carcinoma

  • definitive chemo-radiotherapy
    • UK consensus guidelines recommendations are as follows:
      • utilised as a definitive treatment method for localised squamous cell carcinoma (SCC) of the proximal oesophagus
      • for localised middle or lower oesophageal SCC, chemo-radiotherapy alone or together with surgery can be used
    • randomised trials of CRT followed by surgery versus CRT alone for SCC reported a significant improvement of local progression-free survivaland dysphagia in the surgery groups

  • salvage oesophagectomy after definitive chemoradiation
    • 40%-60% of patients treated with definitive CRT develop locoregional recurrences
    • salvage curative oesophagectomy can be considered in these patients within a multidisciplinary team setting  
    • morbidity and mortality is higher for this method than that of oesophagectomy done in the neoadjuvant setting

  • monoclonal antibody therapy in oesophageal cancer
    • nivolumab
      • is recommended for treating unresectable advanced, recurrent or metastatic oesophageal squamous cell carcinoma in adults after fluoropyrimidine and platinum-based therapy (5)
      • is recommended for adjuvant treatment of completely resected oesophageal or gastro-oesophageal junction cancer in adults who have residual disease after previous neoadjuvant chemoradiotherapy (6)
      • is the first-in-human immunoglobulin G4 (IgG4) PD-1 (programmed cell death-1) immune checkpoint inhibitor antibody that disrupts the interaction of the PD-1 receptor with its ligands PD-L1 (ligand-1) and PD-L2 (ligand-2)
      • PD-1 is an inhibitory receptor expressed on activated T and B cells, which normally function to dampen the immune response
      • inhibition of the interaction between PD-1 and PD-L1 can enhance anti-tumor responses, delay tumor growth, and facilitate tumor rejection

  • palliative therapy
    • should be considered for the following group of patients          
      • in patients with oesophageal carcinomas who are not suitable for treatment with a curative intent due to the  advanced tumour stage or poor physical condition (around 75%)
      • patients who have developed recurrent or metastatic disease following resection
    • main aim is to relive symptoms, prolonging and maximising the quality of life
    • a multi disciplinary approach is required and treatment should be tailored to offer the best possible outcome for the patient
    • may include all or any one of the following therapies:
      • endoscopic stenting
      • brachytherapy
      • chemotherapy
      • external radiotherapy
      • feeding through gastrostomy, jejunostomy, or intravenously
      • pain relief
      • best palliative supportive care (1,2,3)

    • NICE suggest (4):
      • palliative management - non-metastatic oesophageal cancer that is not suitable for surgery
        • chemoradiotherapy should considered for people with non-metastatic oesophageal cancer that can be encompassed within a radiotherapy field
        • when the cancer cannot be encompassed within a high-dose radiotherapy field, consider one or more of:
          • chemotherapy
          • local tumour treatment, including stenting or palliative radiotherapy
          • best supportive care
        • after a person with oesophageal cancer has had treatment, assess the tumour's response to chemotherapy or chemoradiotherapy and reconsider if surgery is an option
      • first-line palliative chemotherapy for locally advanced or metastatic oesophagogastric cancer
          • trastuzumab should be offered (in combination with cisplatin and capecitabine or 5-fluorouracil) as a treatment option to people with HER2-positive metastatic adenocarcinoma of the stomach or gastro-oesophageal junction
        • first-line palliative combination chemotherapy to people with advanced oesophago-gastric cancer who have a performance status 0 to 2 and no significant comorbidities. Possible drug combinations include:
          • doublet treatment: 5-fluorouracil or capecitabine in combination with cisplatin or oxaliplatin
          • triplet treatment: 5-fluorouracil or capecitabine in combination with cisplatin or oxaliplatin plus epirubicin
      • second-line palliative chemotherapy for locally advanced or metastatic oesophagogastric cancer
        • consider second-line palliative chemotherapy for people with oesophagogastric cancer
      • luminal obstruction in oesophageal and gastro-oesophageal junctional cancer
        • options include:
          • self-expanding stents to people with oesophageal and gastro-oesophageal junctional cancer who need immediate relief of dysphagia.
          • self-expanding stents or radiotherapy as primary treatment to people with oesophageal and gastro-oesophageal junctional cancer, depending on the degree of dysphagia and its impact on nutrition and quality of life, performance status and prognosis
          • external beam radiotherapy should be considered after stenting for people with oesophageal and gastro-oesophageal junctional cancer, for long-term disease control

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