Abstract
BackgroundSurvival of patients with cT4 esophageal cancer is dismal. Although the optimal treatment strategy remains to be established, two treatment options are available for cT4 esophageal cancers: definitive chemoradiation (dCRT) and induction treatment followed by conversion surgery (CS). However, little is known concerning the differences in clinical outcome between patients with T4 esophageal tumors treated with dCRT and those eventually treated with CS.MethodsA systematic search of the scientific literature on PubMed/MEDLINE was carried out using the keywords “T4 esophageal cancer,” “invading (involving) adjacent organ,” “definitive chemoradiation,” “induction therapy,” “salvage surgery,” and “conversion surgery,” obtaining 28 reports published up to July 2018.Results/ConclusionWe found that CS was superior to dCRT with respect to local disease control and short‐term survival; however, CS was associated with relatively higher perioperative mortality and morbidity. Alternatively, although dCRT might often cause fistula formation, a clinical complete response to dCRT is likely to lead to a better prognosis. Recent advances in chemotherapeutic agents have led to triple induction chemotherapy, with docetaxel, cisplatin, and 5‐fluorouracil (DCF), which has shown promise as an initial induction treatment for cT4 esophageal cancer. Indeed, this regimen could control both local and systemic disease, which enables curative resection without preoperative CRT. Moreover, some appropriate changes in perioperative management and intensive systemic chemotherapy might enhance patient outcome. Randomized controlled trials with a large sample size are needed to establish the standard treatment for cT4 esophageal cancer.
Highlights
Esophageal cancers tend to invade adjacent organs, including the trachea, bronchus, lung, and aorta, as a result of the lack of serosa in the esophagus and the fact that this conduit is located in a very narrow mediastinal space.[1,2] Tumors that invade adjacent organs are classified as T4, according to the TNM staging system of the International Union against Cancer (UICC)
To our knowledge, there is little or no information on the differences in clinical outcome between patients with T4 esophageal tumors treated with definitive chemoradiation (dCRT) and those eventually treated with conversion surgery (CS)
We focus on these treatments and the outcomes in patients with T4 esophageal cancer, and we discuss future perspectives regarding these modalities
Summary
Esophageal cancers tend to invade adjacent organs, including the trachea, bronchus, lung, and aorta, as a result of the lack of serosa in the esophagus and the fact that this conduit is located in a very narrow mediastinal space.[1,2] Tumors that invade adjacent organs are classified as T4, according to the TNM staging system of the International Union against Cancer (UICC). Esophageal cancer is associated with a high incidence of morbidity and mortality, treating with surgery alone, where neighboring organs are resected together with an esophagectomy, has not improved survival.[4–7]. Definitive chemoradiation (dCRT), a maximum-dose irradiation together with chemotherapy used as a curative treatment which many investigators consider the most suitable treatment for T4 esophageal cancer, has not dramatically contributed to improving patient survival.[8]. According to the Guidelines for Diagnosis and Treatment of Carcinoma of the Esophagus, 2017, the current standard chemotherapeutic regimen for treating esophageal cancer is 5-fluorouracil (5-FU) combined with cisplatin[9] (CF) because of their synergistic radiosensitizing effects.[10]. Previous studies have reported that concurrent CRT with a CF regimen was effective for treating advanced esophageal cancers, including T4 tumors.[1,11]. Two modalities are currently in use for the treatment of cT4 esophageal tumors:[12,13] dCRT14–19 and induction chemotherapy or CRT, followed by conversion surgery (CS).[12,13,20–29]. Some studies showed promising results when induction chemotherapy with the DCF regimen was applied before carrying out CS for cT4 ESCC.[20,24,30] In the present review, we focus on these treatments and the outcomes in patients with T4 esophageal cancer, and we discuss future perspectives regarding these modalities
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