Combined-Modality Treatment of Esophageal Cancer

Until recently, squamous-cell carcinoma comprised the vast majority of cases of esophageal cancer. However, the incidence of adenocarcinoma in white males has been rapidly increasing by approximately 10% per year for the past 10 years. This percentage increase in frequency exceeds that of all other cancers for that time period.[2,3] The prognosis for patients with either type of tumor histology appears to be poor. The two predominant risk factors for the development of esophageal squamous-cell carcinoma are alcohol and tobacco abuse.[4] Adenocarcinoma has been linked to Barrett's metaplasia of the esophageal mucosa as a consequence of chronic gastroesophageal reflux disease. The prevalence of adenocarcinoma in association with Barrett's metaplasia has been found to range from 3% to 16% in various reported series.[5-7] Esophageal cancer patients who have clinically metastatic disease at the time of diagnosis have a median survival of 6 months. Even patients with potentially localized, resectable disease who are treated with surgery have a median survival of approximately 12 months and a 5-year survival of 11% to 14%.[1] The poor prognosis of esophageal cancer relates to its tendency for early spread into the submucosal lymphatic network, as well as to the absence of the serosal layer of the esophagus, which potentially limits local disease extension. Microscopic and/or gross disease is often present in lymph node or distant metastatic sites by the time the primary tumor becomes large enough to cause symptoms of dysphagia. Because of the frequency of disease dissemination at presentation, recent investigations have used systemic therapy combined with locoregional therapies to gain better local control and manage the systemic component of esophageal malignancy.