The role of radiotherapy in the multimodal management of esophageal cancer

Abstract

Despite recent improvements in surgery and radiotherapy, and refinements of systemic treatment options, including incorporation of targeted agents, long-term survival remains poor for patients with esophageal cancer. While surgical resection alone constitutes the standard approach for early-stage disease (stage I), multimodality therapy, including perioperative chemotherapy and neoadjuvant or definitive chemoradiotherapy (CRT), are internationally accepted treatment options for patients with locally advanced disease. In lower esophageal and esophagogastric junction adenocarcinomas, data from large, randomized phase III trials and meta-analyses support the use of both perioperative chemotherapy alone or neoadjuvant concurrent CRT. In patients with locally advanced squamous cell carcinoma (SCC) of the esophagus, neoadjuvant CRT but not neoadjuvant chemotherapy alone is the preferred treatment approach. Definitive CRT without surgery has also emerged as a useful option for the treatment of resectable SCC of the esophagus, avoiding potential surgical morbidity and mortality, with salvage surgery reserved for those with persistent disease. Functional imaging modalities, such as PET-CT, may create new opportunities for a more adequate therapy response assessment and patient selection. Patients with SCC that show clinical response by PET-CT are considered to have a more favorable outcome, regardless of whether surgery will be performed or not. In nonresponding patients, salvage surgery improves survival, especially if complete resection is achieved. Recent technological advances in radiotherapy, such as intensity-modulated radiotherapy, image guided-radiotherapy and PET-CT-based radiotherapy planning, may further improve the therapeutic ratio of CRT. Moreover, the traditional backbone of CRT, platinum plus fluorouracil, may be supplanted by more modern and easier-to-administer regimens incorporating taxanes, irinotecan and targeted agents.