Esophageal Cancer Treatment Protocols

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Esophageal Cancer Treatment Protocols

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Treatment protocols for esophageal cancer are provided below, including recommendations for surgical resection and regimens for the following^[1]:

Tumors shallow to the muscularis propria of the esophagus (Tis or T1) may be treated with endoscopic resection methods: endoscopic mucosal resection (EMR) and the newer, more extensive technique, endoscopic submucosal dissection (ESD), which is preferred for deeper tumors. For early and some locoregional cancers, surgery is the primary treatment. Esophagectomy may be performed using either the standard open approach or a minimally invasive procedure.

For chemotherapy, two-drug cytotoxic regimens that include a platinum agent are generally preferred for first-line therapy. Second-line and subsequent therapy may involve single agents (eg, with taxanes) or molecular therapy such as ramucirumab to target vascular endothelial growth factor (VEGF) receptor or trastuzumab for metastatic adenocarcinoma that overexpresses human epidermal growth factor receptor 2 (HER2 ).^[1]

Radiation therapy is often given with chemotherapy. External beam radiation therapy (EBRT) is used.

A study by Fogh et al of induction chemoradiotherapy followed by surgery, a strategy that is widely used in treating esophageal cancer, found that perioperative morbidity and mortality with this approach was not significantly different in patients aged 70 years or older compared with younger patients. Consequently, these authors suggest using this strategy in elderly patients.^[2]

The following recommendations are based on tumor/node/metastasis (TNM)–based stages. Stage I, II, and III esophageal cancers are all potentially resectable.

For Tis-T1a, N0, M0 disease, treatment options are as follows:

For T1b, N0, M0 disease, treatment options are as follows:

For T2/T3, N0, M0 disease, treatment options are as follows:

For T3, N1, M0 to T1-3, N2, M0 disease, chemoradiotherapy with or without esophagectomy is recommended

For T4, N0-2, M0-1 disease, treatment options are as follows:

Neoadjuvant chemoradiotherapy appears to be associated with better survival than local therapy or surgery alone.^[3] Regimens are listed below according to National Comprehensive Cancer Network (NCCN) categories of evidence: Category 1 recommendations are based on high-level evidence, while category 2A recommendations are based on lower-level evidence. With both categories, there is uniform NCCN consensus that the intervention is appropriate.

See the list below:

Perioperative chemotherapy with regimens such as ECF (epirubicin, cisplatin, and 5-FU) has led to significant improvement in overall survival in patients with operable lower esophageal adenocarcinomas. Treatment recommendations include three cycles preoperatively and three cycles postoperatively of ECF, only for adenocarcinoma of the distal esophagus or gastroesophageal junction.

The following are NCCN category 1 regimens (ie, supported by high-level evidence):

Definitive chemoradiotherapy is used in patients with unresectable nonmetastatic esophageal cancer. The following are NCCN category 1 regimens (ie, supported by high-level evidence):

The following are NCCN category 2A regimens (ie, supported by a lower level of clinical evidence):

Surgery can be the initial treatment of choice for patients with adenocarcinoma; however, it is advisable to treat these patients with postoperative chemoradiotherapy because of an evidence-based increase in survival. The following are NCCN category 1 regimens (ie, supported by high-level evidence):

Trastuzumab should be added to first-line chemotherapy for metastatic adenocarcinomas that overexpress HER2. However, it is not recommended for use with anthracyclines.^[1]

The following are NCCN category 1 regimens (ie, supported by high-level evidence):

The following are NCCN category 2A regimens (ie, supported by a lower level of clinical evidence):

Category 1 recommendations for second-line therapy based on high level of clinical evidence, are as follows:

Category 2A recommendations for second-line therapy, based on lower level of clinical evidence, include the following:

See the list below:

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Mohammad Muhsin Chisti, MD, FACP Assistant Professor of Hematology and Oncology, Medical Director of Research, Karmanos Cancer Institute, Wayne State University School of Medicine

Mohammad Muhsin Chisti, MD, FACP is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Clinical Oncology, American Society of Hematology, Medical Society of the State of New York