Current treatment strategies of oesophageal carcinoma

Recent progress in the prognosis of patients with oesophageal cancer appears rather to reflect better patient selection and improved perioperative management than efficacy of the therapy. There are still a lot of controversies regarding treatment strategies due to lack of studies with adequate patient numbers and the inclusion of heterogeneous study populations. Surgery alone showed high rates of locoregional and distant failure for patients with locally advanced stages and consequently a 3 y-survival rate of only 15–20%. Postoperative radiotherapy and chemotherapy were usually not feasible due to the morbidity of the oesophagectomy. Preoperative chemotherapy showed a significant but only modest improvement in overall survival over surgery alone. Most studies investigating neoadjuvant chemoradiation were under-powered and showed no significant difference; however, in several meta-analyses a significant reduction of tumour related death rate could be shown at the expense of an increased postoperative mortality. Two European trials randomized mainly squamous cell cancer patients to chemoradiation with or without surgery. The designs of these two trials were slightly different. Both showed an increased mortality rate linked with surgery, a better locoregional control with surgery and no significant difference of overall survival according to their prospective hypothesis. The results of these trials have been controversially discussed. No general guideline of a treatment strategy is possible, because too many variables have to be considered such as histology, tumour localization, response to neoadjuvant therapy, co-morbidity, performance status and age of the patient. Personal conclusions and recommendations of the authors were discussed.