A meta-analysis of randomized controlled trials that compared neoadjuvant chemoradiation and surgery to surgery alone for resectable esophageal cancer

Neoadjuvant treatment for gastric cancer

Surgery is still considered to be the mainstay for the treatment of localized gastric cancer with negative margins (R0-resection) and an adequate lymph-node-dissection (D2-lymphadenectomy). Unfortunately, most cases of gastric cancer are only diagnosed at an advanced stage due to frequent recurrences after primary resection in curative intent. In order to improve prognosis after curative resection, in the recent past, patients with locally advanced tumors were subjected to a pre-, peri-, or postoperative treatment. Interestingly, postoperative chemotherapy has significantly improved survival after gastric resection in Asia, adjuvant radiochemotherapy is favored in North America and perioperative chemotherapy is considered as a treatment of choice in Europe indicating region specific approach towards the treatment. Recently there has also been growing evidence of positive outcomes of neoadjuvant radiochemotherapy on patient survival. In the present article, we discuss the concepts of neoadjuvant treatment approach and provide recommendations to surgeons based on current evidence.

Oncogenic role of protein tyrosine kinase 7 in esophageal squamous cell carcinoma

Esophageal squamous cell carcinoma (ESCC) is a common subtype of esophageal cancer that is particularly prevalent in East Asian countries. Our previous expression profile analysis showed that the gene encoding protein tyrosine kinase 7 (PTK7) is upregulated in ESCC tissues. Here, we aimed to validate PTK7 as a prognostic factor and a candidate target for molecular treatment of ESCC. Both RT-PCR and Western blot analysis of tissues from ESCC patients revealed that PTK7 was significantly upregulated in tumor tissue samples of ESCC. Immunohistochemical staining of PTK7 showed that increased expression of PTK7 was inversely correlated with overall survival (P = 0.021). In vitro knockdown of PTK7 inhibited proliferation, survival, wound healing, and invasion of ESCC cells. In addition, PTK7 knockdown decreased phosphorylation of Akt, Erk, and focal adhesion kinase (FAK), important determinants of cell proliferation, survival, and migration. Therefore, our findings suggest that PTK7 has potential as a prognostic marker for ESCC and might also be a candidate for targeted therapy in the treatment of ESCC.

Role of BAX for outcome prediction in gastrointestinal malignancies

Our group and numerous others have shown in both preclinical and clinical studies that the proapoptotic mediator BAX may be deregulated through gene mutation or loss of protein expression, affecting resistance to chemotherapy and radiotherapy in several cancer types. However, BAX is also involved in cancer development and may related to prognosis, independently of treatment outcome. The clinical impact of BAX status in gastrointestinal malignancies remains controversial, although it is generally hypothesized that high expression may be a positive prognostic factor and predict increased efficacy of chemotherapy (with particular regard to platinum derivatives). The present review aims to provide updated information on BAX as potential prognostic and/or predictive biomarker in gastroesophageal and colorectal cancers, as well as in other less studied gastrointestinal malignancies.

Accuracy of multidetector-row CT for restaging after neoadjuvant treatment in patients with oesophageal cancer

OBJECTIVES

To assess the diagnostic accuracy of 64-multidetector CT (MDCT) for restaging of patients with oesophageal cancer undergoing neoadjuvant therapy.

METHODS

Results of pathological staging were correlated with those from 64-MDCT before and after neoadjuvant treatment in 35 patients using the American Joint Committee on Cancer/TNM classification (7th edition). CT response was determined using the Response Evaluation Criteria in Solid Tumours (RECIST) method, modified for one-dimensional tumour diameter measurement.

RESULTS

64-MDCT predicted T stage correctly in 34 % (12/35), overstaged in 49 % (17/35) and understaged in 17 % (6/35). Sensitivity/specificity values were as follows: T0, 20 %/92 %; T1-T2, 31 %/59 %; T3, 60 %/64 %; T4, 100 %/4 %. Negative predictive values for T3/T4 were 80 %/100 %. MDCT accurately predicted complete histopathological response in 20 % (accuracy 74 %) and overstaged in 80 %. Tumour regression grade was predicted correctly in only 8 % (2/25) and underestimated in 68 % (17/25). Accurate N stage was noted in 69 % (24/35).

CONCLUSION

Although MDCT tends to be able to exclude advanced tumour stages (T3, T4) with a higher likelihood, the diagnostic accuracy of high resolution MDCT for restaging oesophageal cancer and assessing the response to neoadjuvant therapy has not improved in comparison to older-generation CT. Therefore, the future assessment of oesophageal tumour response should focus on combined morphologic and metabolic imaging.

KEY POINTS

• Multidetector CT (MDCT) has been beneficial for the evaluation of many tumours. • However diagnostic accuracy for restaging oesophageal cancer has not improved with MDCT. • MDCT tends to be able to exclude advanced tumour stages (T3/T4). • MDCT has a low accuracy for determining lymph node metastasis. • Oesophageal tumour response should be assessed by combined morphological and metabolic imaging.

Results of management of esophageal and GE junction malignancies in Nepalese context

BACKGROUND

Optimal management of esophageal and GE junction cancer in Nepal has not been studied properly. We reviewed our results to recommend some practical guidelines.

METHODS

An institutional review of 327 patients was done. Locally advanced cases were subjected to neoadjuvant treatment prior to surgery, whereas resectable cases were directly subjected to surgery or surgery followed by adjuvant treatment. Open and minimally invasive approaches were used in 246 (75%) and 81 (25%) patients, respectively.

RESULTS

Final stages showed Ia (0.3%), Ib (2%), IIa (13%), IIb (8%), IIIa (17%), IIIb (11%), IIIc (41.7%) and IV (7%). The post operative mortality was 5.8%. Pneumonia/ pneumonitis, anastomotic leak and hoarseness of voice were observed in 21%, 11.6% and 7.6%, respectively. Median survival (in months) was as follows: St Ia - 60, Ib - 15, IIa - 23, IIb - 18, IIIa - 15, IIIb - 15, IIIc - 11 and IV - 8.5 (P<0.001). R0 and R+ resection was achieved in 299 (91%) and 28 (9%) cases, respectively with median survival of 27 and 9 months in R0 and R+ resections, respectively (P<0.001). 5-year overall survival was 22% with median survival of 25 months. After neoadjuvant treatment, Complete responders had median survival of 25.1 vs. 12.6 months for non-responders (P=0.042).

CONCLUSION

Though the postoperative complications remain in acceptable range, the overall survival remains poor mainly due to the advanced stage of the disease at the time of diagnosis. Therefore, an approach of neoadjuvant chemoradiation/ chemotherapy prior to the surgery should be encouraged whenever feasible in order to achieve the best results.

Radiation Therapy and Esophageal Cancer

Background

Squamous cell carcinoma and adenocarcinoma account for more than 90% of all esophageal cancer cases. Although the incidence of squamous cell carcinoma has declined, the incidence of adenocarcinoma has risen due to increases in obesity and gastroesophageal reflux disease.

Methods

The authors examine the role of radiation therapy alone (external beam and brachytherapy) for the management of esophageal cancer or combined with other modalities. The impact on staging and appropriate stratification of patients referred for curative vs palliative intent with modalities is reviewed. The authors also explore the role of emerging radiation technologies.

Results

Current data show that neoadjuvant chemoradiotherapy followed by surgical resection is the accepted standard of care, with 3-year overall survival rates ranging from 30% to 60%. The benefit of adjuvant radiation therapy is limited to patients with node-positive cancer. The survival benefit of surgical resection after chemoradiotherapy remains controversial. External beam radiation therapy alone results in few long-term survivors and is considered palliative at best. Radiation dose-escalation has failed to improve local control or survival. Brachytherapy can provide better long-term palliation of dysphagia than metal stent placement. Although three-dimensional conformal treatment planning is the accepted standard, the roles of IMRT and proton therapy are evolving and potentially reduce adverse events due to better sparing of normal tissue.

Conclusions

Future directions will evaluate the benefit of induction chemotherapy followed by chemoradiotherapy, the role of surgery in locally advanced disease, and the identification of responders prior to treatment based on microarray analysis.

The Impact of Age on Morbidity and Mortality following Esophagectomy for Esophageal Cancer

Background

In patients with esophageal cancer, treatment decisions often involve a balance between a high-risk procedure and the chance for long-term benefit. The decision can be additionally challenging for elderly patients since some studies have reported an increased incidence of morbidity and mortality in this age group, and data are not clear on the overall benefit of multimodality therapy.

Methods

To investigate the management and outcomes associated with esophagectomy in elderly patients with esophageal cancer, we performed a review of the literature as well as an analysis of our own institutional data, with a focus on the impact of age on surgical outcomes. We examined type of surgery, neoadjuvant and adjuvant therapy, postoperative complications, length of hospitalization, and mortality as variables in elderly patients with esophageal cancer.

Results

When assessing the impact of age on the success of esophagectomy, several studies have concluded that advanced age itself is not a predictor of outcomes as much as associated comorbidities are. Our own experience suggests that age is not associated with adverse outcomes when controlling for patient comorbidities. This finding is similar to data reported elsewhere.

Conclusions

When considering treatment for patients of advanced age, the risks of treatment should be compared with the survival benefits of the therapy prescribed, taking into account additional factors such as poor performance status, existing comorbidities, and residual tumor following neoadjuvant therapy. Many reports, as well as our own experience, have concluded that when adjusted for comorbidities, patient age does not significantly affect outcomes.

Oesophageal cancer--an overview

Oesophageal carcinoma is one of the most virulent malignant diseases and a major cause of cancer-related deaths worldwide. Diagnosis and accuracy of pretreatment staging have substantially improved throughout the past three decades. Therapy is challenging and the optimal approach is still debated. Oesophagectomy is considered to be the procedure of choice in patients with operable oesophageal cancer. Endoscopic measures and limited surgical procedures provide an alternative in patients with early carcinomas confined to the oesophageal mucosa. Chemotherapy and radiotherapy or concurrent chemoradiotherapy are also frequently applied, either as definitive treatment or as neoadjuvant therapy within multimodal approaches. The question of whether multimodal treatment offers improved results has been the focus of many studies since the 1990s. Although results are discordant and even some meta-analyses remain inconclusive, it is now widely accepted that multimodal therapy leads to a modest survival benefit. The role of minimally invasive oesophagectomy is not yet defined. Endoscopic stent insertion, radiotherapy and other palliative measures provide relief of tumour-related symptoms in advanced, unresectable tumour stages.

Lymph node invasion might have more prognostic impact than R status in advanced esophageal adenocarcinoma

BACKGROUND

Advanced esophageal adenocarcinomas are associated with 5-year survival rates ranging from 14% to 35%. Nodal status and tumor clearance are the main prognostic factors. However, their respective prognostic values have not been compared to date.

METHODS

Seventy consecutive patients with stage T3 adenocarcinomas of the esophagus or gastric cardia were retrospectively assessed. Neoadjuvant therapy was indicated in all cases. Prognostic values of R0 resection and nodal status were evaluated using univariate and multivariate analyses.

RESULTS

Neoadjuvant therapy was achieved in 62 patients, 41 with radiochemotherapy and 21 with perioperative chemotherapy. Transthoracic esophagectomy and transhiatal esophagectomy were performed in 54 and 15 patients, respectively. Clavien-Dindo grade III or IV complications occurred in 16 patients (23%). Two patients died in the hospital (3%). In univariate and multivariate analyses, nodal status was the main independent factor predicting overall survival; tumor clearance (R0 or R1) had less prognostic impact and was not statistically significant. Furthermore, R1 resection was a prognostic indicator for metastatic recurrence.

CONCLUSIONS

These results indicate that nodal status has more prognostic impact than R status in stage T3 adenocarcinomas of the esophagus or gastric cardia. Thus, local control in R1 patients by postoperative radiotherapy is not justified.

Prospective, open, multi-centre phase I/II trial to assess safety and efficacy of neoadjuvant radiochemotherapy with docetaxel and oxaliplatin in patients with adenocarcinoma of the oesophagogastric junction

Background

This phase I/II-trial assessed the dose-limiting toxicities (DLT) and maximum tolerated dose (MTD) of neoadjuvant radiochemotherapy (RCT) with docetaxel and oxaliplatin in patients with locally advanced adenocarcinoma of the oesophagogastric junction.

Methods

Patients received neoadjuvant radiotherapy (50.4 Gy) together with weekly docetaxel (20 mg/m² at dose level (DL) 1 and 2, 25 mg/m² at DL 3) and oxaliplatin (40 mg/m² at DL 1, 50 mg/m² at DL 2 and 3) over 5 weeks. The primary endpoint was the DLT and the MTD of the RCT regimen. Secondary endpoints included overall response rate (ORR) and progression-free survival (PFS).

Results

A total of 24 patients were included. Four patients were treated at DL 1, 13 patients at DL 2 and 7 patients at DL 3. The MTD of the RCT was considered DL 2 with docetaxel 20 mg/m² and oxaliplatin 50 mg/m². Objective response (CR/PR) was observed in 32% (7/22) of patients. Eighteen patients (75%) underwent surgery after RCT. The median PFS for all patients (n = 24) was 6.5 months. The median overall survival for all patients (n = 24) was 16.3 months. Patients treated at DL 2 had a median overall survival of 29.5 months.

Conclusion

Neoadjuvant RCT with docetaxel 20 mg/m² and oxaliplatin 50 mg/m² was effective and showed a good toxicity profile. Future studies should consider the addition of targeted therapies to current neoadjuvant therapy regimens to further improve the outcome of patients with advanced cancer of the oesophagogastric junction.

Trial Registration

NCT00374985

Multidisciplinary management of esophageal cancer

This article reviews the current management of esophageal cancer, including staging and treatment options, as well as providing support for using multidisciplinary teams to better manage esophageal cancer patients.

The rationale and evidence for radiotherapy in the management of gastroesophageal junction tumors

Adenocarcinoma of the gastroesophageal junction (GE-junction) is a frequent disease with a rising incidence. The optimal treatment of localized disease is the subject of many randomized trials and meta-analyses studying the role of preoperative chemotherapy or preoperative chemoradiation compared with surgery alone. A complicating factor in interpreting the results of these trials is the fact that GE-junction tumors are sometimes regarded as esophageal tumors, although in other studies they are regarded as gastric cancers. A thorough review of the literature including meta-analyses clearly indicates that there is a role for preoperative chemoradiation in locally advanced GE-junction tumors. Based on the available evidence a surgery alone arm in future randomized trials for locally advanced GE junction tumors can no longer be regarded as a standard arm.

Neoadjuvant concurrent chemoradiotherapy for locally advanced esophageal cancer in a single high-volume center

BACKGROUND

Neoadjuvant chemoradiotherapy (CRT) is now considered the standard of care by many centers in the treatment of both squamous cell carcinoma (SCC) and adenocarcinoma of the esophagus. This study evaluates the effectiveness of a neoadjuvant CRT protocol, as regards pathological complete response (pCR) rate and long-term survival.

METHODS

From 2003 to 2011, at Upper G.I. Surgery Division of Verona University, 155 consecutive patients with locally advanced esophageal cancers (90 SCC, 65 adenocarcinoma) were treated with a single protocol of neoadjuvant CRT (docetaxel, cisplatin, and 5-fluorouracil with 50.4 Gy of concurrent radiotherapy). Response to CRT was evaluated through percentage of pathological complete response (pCR or ypT0N0), overall (OS) and disease-related survival (DRS), and pattern of relapse.

RESULTS

One hundred thirty-one patients (84.5 %) underwent surgery. Radical resection (R0) was achieved in 123 patients (79.3 %), and pCR in 65 (41.9 %). Postoperative mortality was 0.7 % (one case). Five-year OS and DRS were respectively 43 and 49 % in the entire cohort, 52 and 59 % in R0 cases, and 72 and 81 % in pCR cases. Survival did not significantly differ between SCC and adenocarcinoma, except for pCR cases. Forty-nine patients suffered from relapse, which was mainly systemic in adenocarcinoma. Only three out of 26 pCR patients with previous adenocarcinoma developed relapse, always systemic.

CONCLUSIONS

This study suggests that patients treated with the present protocol achieve good survival and high pCR rate. Further research is necessary to evaluate whether surgery on demand is feasible in selected patients, such as pCR patients with adenocarcinoma.

Multi-modality therapy for cancer of the esophagus and GE junction

Cancers of the esophagus and gastroesophageal junction (GEJ) are associated with a high mortality rate. In the United States, the incidence of adenocarcinoma of the distal esophagus and GEJ is rising at an alarming rate. Decades of investigation have established the impact on survival of neoadjuvant platinum-based chemotherapy as well as chemoradiation for locally advanced tumors. Distant recurrence remains the most common pattern of failure and efforts to improve therapeutic outcome should focus on optimizing systemic therapy. Induction chemotherapy before preoperative chemoradiation and postoperative adjuvant chemotherapy are approaches to intensify systemic therapy delivery and deserve further investigation. The integration of targeted therapies and development of predictive biomarkers to identify subgroups of patients who are likely to benefit will mark the future of neoadjuvant treatment in this disease.

Multidisciplinary approach for patients with esophageal cancer

Patients with esophageal cancer have a poor prognosis because they often have no symptoms until their disease is advanced. There are no screening recommendations for patients unless they have Barrett's esophagitis or a significant family history of this disease. Often, esophageal cancer is not diagnosed until patients present with dysphagia, odynophagia, anemia or weight loss. When symptoms occur, the stage is often stage III or greater. Treatment of patients with very early stage disease is fairly straight forward using only local treatment with surgical resection or endoscopic mucosal resection. The treatment of patients who have locally advanced esophageal cancer is more complex and controversial. Despite multiple trials, treatment recommendations are still unclear due to conflicting data. Sadly, much of our data is difficult to interpret due to many of the trials done have included very heterogeneous groups of patients both histologically as well as anatomically. Additionally, studies have been underpowered or stopped early due to poor accrual. In the United States, concurrent chemoradiotherapy prior to surgical resection has been accepted by many as standard of care in the locally advanced patient. Patients who have metastatic disease are treated palliatively. The aim of this article is to describe the multidisciplinary approach used by an established team at a single high volume center for esophageal cancer, and to review the literature which guides our treatment recommendations.

Management of advanced-stage operable esophageal cancer

The incidence of esophageal cancer is increasing in the developed world, with a relative increase in adenocarcinoma compared with squamous cell carcinoma. The distensible nature of the esophagus results in delayed development of symptoms associated with esophageal cancer; hence many patients have locally advanced or metastatic cancer at the time of initial presentation. Although resection remains the treatment of choice for early-stage esophageal cancer, the best treatment strategy for locally advanced esophageal cancer is debatable and, consequently, varies at different centers. This article discusses the published literature on various available therapeutic options for the treatment of locally advanced esophageal cancer.

Neoadjuvant chemoradiotherapy could improve survival outcomes for esophageal carcinoma: a meta-analysis

BACKGROUND

The effectiveness of neoadjuvant chemoradiotherapy in patients with resectable esophageal carcinoma remains controversial.

AIMS

The purpose of this study was to assess the effect of neoadjuvant chemoradiotherapy on operable esophageal carcinoma.

METHODS

We searched PubMed, EMBASE and Web of Science and identified all randomized controlled trials published up until July 2011 that directly compared chemoradiotherapy followed by surgery with surgery alone. The risk ratio (RR) with its corresponding 95 % confidence interval (CI) was the principal measure of effects.

RESULTS

Twelve randomized controlled trials that met our inclusion criteria were identified. Chemoradiotherapy followed by surgery was associated with significantly improved 1-year (RR = 0.86, 95 % CI = 0.74-0.98, P = 0.03), 3-year (RR = 0.82, 95 % CI = 0.73-0.92, P = 0.0007) and 5-year (RR = 0.83, 95 % CI = 0.72-0.96, P = 0.01) survival times compared with surgery alone. Subgroup analysis suggested that this benefit was associated with concurrent chemoradiotherapy but not sequential chemoradiotherapy. Neoadjuvant chemoradiotherapy could improve 3- and 5-year survival outcomes for squamous cell carcinoma but not those for adenocarcinoma. Postoperative morbidity (RR = 0.97, 95 % CI = 0.86-1.09, P = 0.56) and mortality (RR = 1.56, 95 % CI = 0.97-2.50, P = 0.07) did not increase in patients treated by chemoradiotherapy.

CONCLUSIONS

Our findings revealed that compared with surgery alone, neoadjuvant chemoradiotherapy was associated with improved 1-, 3- and 5-year survival times, but not associated with increased postoperative morbidity and mortality in patients with esophageal carcinoma.

Prognostic significance of circumferential resection margin involvement following oesophagectomy for cancer and the predictive role of endoluminal ultrasonography

Background:

The optimum multimodal treatment for oesophageal cancer, and the prognostic significance of histopathological tumour involvement of the circumferential resection margin (CRM+) are uncertain. The aims of this study were to determine the prognostic significance of CRM+ after oesophagectomy and to identify endosonographic (endoluminal ultrasonography (EUS)) features that predict a threatened CRM+.

Methods:

Two hundred and sixty-nine consecutive patients underwent potentially curative oesophagectomy (103 surgery alone, 124 neoadjuvant chemotherapy (CS) and 42 chemoradiotherapy (CRTS)). Primary outcome measures were disease-free survival (DFS) and overall survival (OS).

Results:

CRM+ was reported in 98 (38.0%) of all, and in 90 (62.5%) of pT3 patients. Multivariate analysis of pathological factors revealed: lymphovascular invasion (HR 2.087, 95% CI 1.396–3.122, P<0.0001), CRM+ (HR 1.762, 95% CI 1.201–2.586, P=0.004) and lymph node metastasis count (HR 1.563, 95% CI 1.018–2.400, P=0.041) to be independently and significantly associated with DFS. Lymphovascular invasion (HR 2.160, 95% CI 1.432–3.259, P<0.001) and CRM+ (HR 1.514, 95% CI 1.000–2.292, P=0.050) were also independently and significantly associated with OS. Multivariate analysis revealed EUS T stage (T3 or T4, OR 24.313, 95% CI 7.438–79.476, P<0.0001) and use or not of CRTS (OR 0.116, 95% CI 0.035–0.382, P<0.0001) were independently and significantly associated with CRM+.

Conclusion:

A positive CRM was a better predictor of DFS and OS than standard pTNM stage.

Neoadjuvant therapy with weekly docetaxel and cisplatin, 5-fluorouracil continuous infusion, and concurrent radiotherapy in patients with locally advanced esophageal cancer produced a high percentage of long-lasting pathological complete response: a phase 2 study

BACKGROUND

This phase 2 study was aimed at defining the pathological response rate of a neoadjuvant schedule including weekly docetaxel and cisplatin, continuous infusion (c.i.) of 5-fluorouracil (5-FU) and concomitant radiotherapy (RT) in untreated stage II-III adenocarcinoma and squamous cell carcinoma of mid-distal thoracic esophagus.

METHODS

The schedule consisted of a first phase of chemotherapy alone and of a second phase of concurrent chemoradiation. Doses were as follows: docetaxel 35 mg/m(2) and cisplatin 25 mg/m(2) on days 1, 8, 15, 29, 36, 43, 50, and 57 plus 5-FU c.i. (180 mg/m(2) on days 1-21 and 150 mg/m(2) on days 29-63); RT (50 Gy) started at day 29. Surgery was planned 6 to 8 weeks after the completion of chemoradiation.

RESULTS

A total of 74 patients were enrolled; pathological complete remission (pCR) was found in 47% (35 of 74) and near pCR (microfoci of tumor cells on the primary tumor without lymph nodal metastases) (pnCR) in 15% of the patients (11 of 74). Grade 3-4 neutropenia, nonhematological toxicity, and toxic deaths occurred in 13.5%, 32.4%, and 4% of the patients, respectively. Median follow-up was 55 months (range, 3-108 months). Median survival of all 74 patients was 55 months, whereas it was not reached in the pCR subset. The 3- and 5-year survival rates were, respectively, 83% and 77% for pCR, 73% and 44% for pnCR, and 21% and 14% for Residual Tumor subsets (P < .001).

CONCLUSIONS

This study shows that 1) this intensive weekly schedule produced a high pathological response rate, 2) responders had high and long-term durable survival rates.

Radiotherapy for tumors of the stomach and gastroesophageal junction--a review of its role in multimodal therapy

There is broad consensus on surgical resection being the backbone of curative therapy of gastric- and gastroesophageal junction carcinoma. Nevertheless, details on therapeutic approaches in addition to surgery, such as chemotherapy, radiotherapy or radiochemotherapy are discussed controversially; especially whether external beam radiotherapy should be applied in addition to chemotherapy and surgery is debated in both entities and differs widely between regions and centers. Early landmark trials such as the Intergroup-0116 and the MAGIC trial must be interpreted in the context of potentially insufficient lymph node resection. Despite shortcomings of both trials, benefits on overall survival by radiochemotherapy and adjuvant chemotherapy were confirmed in populations of D2-resected gastric cancer patients by Asian trials.

Recent results on junctional carcinoma patients strongly suggest a survival benefit of neoadjuvant radiochemotherapy in curatively resectable patients. An effect of chemotherapy in the perioperative setting as given in the MAGIC study has been confirmed by the ACCORD07 trial for junctional carcinomas; however both the studies by Stahl et al. and the excellent outcome in the CROSS trial as compared to all other therapeutic approaches indicate a superiority of neoadjuvant radiochemotherapy as compared to perioperative chemotherapy in junctional carcinoma patients. Surgery alone without neoadjuvant or perioperative therapy is considered suboptimal in patients with locally advanced disease.

In gastric carcinoma patients, perioperative chemotherapy has not been compared to adjuvant radiochemotherapy in a randomized setting. Nevertheless, the results of the recently published ARTIST trial and the Chinese data by Zhu and coworkers, indicate a superiority of adjuvant radiochemotherapy as compared to adjuvant chemotherapy in terms of disease free survival in Asian patients with advanced gastric carcinoma. The ongoing CRITICS trial is supposed to provide reliable conclusions about which therapy should be preferred in Western patients with gastric carcinoma. If radiotherapy is performed, modern approaches such as intensity-modulated radiotherapy and image guidance should be applied, as these methods reduce dose to organs at risk and provide a more homogenous coverage of planning target volumes.

Multimodality approach for locally advanced esophageal cancer

Carcinoma of the esophagus is an aggressive and lethal malignancy with an increasing incidence worldwide. Incidence rates vary internationally, with the highest rates found in Southern and Eastern Africa and Eastern Asia, and the lowest in Western and Middle Africa and Central America. Patients with locally advanced disease face a poor prognosis, with 5-year survival rates ranging from 15%-34%. Recent clinical trials have evaluated different strategies for management of locoregional cancer; however, because of stage migration and changes in disease epidemiology, applying these trials to clinical practice has become a daunting task. We searched Medline and conference abstracts for randomized studies published in the last 3 decades. We restricted our search to articles published in English. Neoadjuvant chemoradiotherapy followed by surgical resection is an accepted standard of care in the United States. Esophagectomy remains an essential component of treatment and can lead to improved overall survival, especially when performed at high volume institutions. The role of adjuvant chemotherapy following curative resection is still unclear. External beam radiation therapy alone is considered palliative and is typically reserved for patients with a poor performance status.

[The role of neoadjuvant therapy in the treatment of locally advanced squamous cell cancer of the cervical oesophagus]

INTRODUCTION

Cervical oesophagus represents a critical location for squamous cell carcinoma, which usually requires extensive surgery (pharyngo-laryngo-oesophagectomy). In the last decade, neoadjuvant chemo-radiotherapy was reported to be beneficial in the treatment of locally advanced squamous cell oesophageal cancer.

METHODS

Between November 1997 and January 2012, 55 patients with locally advanced (T3-4) squamous cell oesophageal cancer received preoperative chemo-radiotherapy, where the tumour was localized in the upper third. Patients received preoperative irradiation of 3960 cGy in 180 cGy fractions and simultaneously Cisplatin and 5-FU chemotherapy. Restaging was carried out after four weeks and patients considered operable were underwent surgery.

RESULTS

In patients with cervical oesophageal cancer 35 of 55 (64%) underwent oesophageal resection or pharyngo-laryngectomy. In 16 out of 35 resected specimens (46%) complete histopathological remission (pCR) was observed. Perioperative mortality and anastomotic leaks were the same: 5/35 (14%). R0 resection rate was 82% and the 2- and 5 years survival rates were 41% and 18%. In 19 cases a larynx preserving pharyngo-oesophagectomy was performed and a free jejunal graft was used for reconstruction after a pharyngo-laryngectomy in 11 cases.

CONCLUSION

The high rate of pCR (46%) confirmed that upper third oesophageal cancer has superior sensitivity to multimodal treatment. In 30 cases neoadjuvant chemo-radiotherapy was able to achieve tumour regression and render pharyngo-laryngo-oesophagectomy unnecessary.

Multimodal treatment of esophageal cancer

BACKGROUND

The treatment of localized esophageal cancer has been debated controversially over the past decades. Neoadjuvant treatment was used empirically, but evidence was limited due to the lack of high-quality confirmatory studies. Meanwhile, data have become much clearer due to recently published well-conducted randomized controlled trials and meta-analyses.

METHODS

Neoadjuvant and perioperative platinum fluoropyrimidine-based combination chemotherapy has now an established role in the treatment of stage II and stage III esophageal adenocarcinoma and cancer of the esophago-gastric junction. Neoadjuvant chemoradiation is now the standard of care for treating stage II and stage III esophageal squamous cell cancer and can also be considered for treating esophageal adenocarcinoma.

RESULTS

Patients with esophageal squamous cell cancer treated with definitive chemoradiation achieve comparable long-term survival compared with surgery. Short-term mortality is less with chemoradiation alone, but local tumor control is significantly better with surgery.

CONCLUSION

This expert review article outlines current data and literature and delineates recommendable treatment guidelines for localized esophageal cancer.

A phase II study of concurrent chemoradiotherapy with weekly docetaxel and cisplatin in advanced oesophageal cancer

BACKGROUND

Concurrent chemoradiotherapy (CRT) is a main treatment option for patients with advanced oesophageal cancer. However, improvement of survival outcomes and toxicities according to the selected treatment is still needed. This phase II trial was conducted to assess the efficacy and safety of concurrent CRT with weekly docetaxel and cisplatin in advanced oesophageal cancer.

METHODS

Patients with unresectable oesophageal cancer due to advanced stage or patients medically unfit for surgery were enrolled. Patients received 20 mg/m(2) docetaxel and 25 mg/m(2) cisplatin in weeks 1, 2, 3, 5, 6, and 7 with concurrent 54-Gy radiotherapy at 200 cGy/day.

RESULTS

Thirty-six patients with oesophageal squamous cell carcinoma were enrolled from December 2007 to December 2009. Among them, the toxicity and response rate of 35 were evaluated. Thirty-five patients completed radiotherapy as planned, and 33 completed chemotherapy as planned. Grade 3 or 4 toxicity during CRT included leucopenia (5.7 %), febrile neutropenia (2.9 %), oesophagitis (22.9 %), and tracheo-oesophageal fistula (5.7 %). After CRT, 8 patients (22.9 %) had a complete response, 22 (62.9 %) had a partial response, 4 (11.4 %) had stable disease, and 1 (2.9 %) had progressive disease. Improvement of dysphagia was observed in 85.3 %. At a median follow-up of 26.7 months, the median time to progression was 13.5 months, and median overall survival was 26.9 months. The 3-year progression-free survival rate was 16.7 %, and survival rate was 27.8 %.

CONCLUSION

Concurrent CRT with weekly docetaxel and cisplatin was well tolerated and is a convenient combination with promising efficacy. This result indicated favourable activity in terms of both tumour and symptom control.

Salvage concurrent radio-chemotherapy for post-operative local recurrence of squamous-cell esophageal cancer

Purpose

To evaluate the treatment outcome of salvage concurrent radio-chemotherapy for patients with loco-recurrent esophageal cancer after surgery.

Methods

50 patients with loco-recurrent squamous-cell cancer after curative esophagectomy were retrospectively analyzed. Patients were treated with radiotherapy (median 60 Gy) combined with chemotherapy consisting of either 5-fluorouracil (5-FU) plus cisplatin (DDP) (R-FP group) or paclitaxel plus DDP (R-TP group).

Results

The median follow-up period was 16.0 months. The 1-year and 3-year survival rates were 56% and 14%, respectively. The median progression-free survival (PFS) and overall survival (OS) time was 9.8 and 13.3 months respectively. There was no statistical significance of the PFS of the two groups. The OS (median 16.3 months) in the R-TP group was superior to that in the R-FP group (median: 9.8 months) (p = 0.012). Among the patients who had received ≥60 Gy irradiation dose, the median PFS (10.6 months) and OS (16.3 months) were significantly superior to the PFS (8.7 months) and OS (11.3 months) among those patients did not (all p < 0.05). Grade 3 treatment-related gastritis were observed in 6 (27.3%) and 7 (25%) patients in the R-FP and R-TP group respectively. By univariate survival analysis, the age (<60 years), TP regimen and higher irradiation dose might improve the OS of such patients in present study.

Conclusions

For those patients with post-operative loco-recurrent squamous-cell esophageal carcinoma, radiotherapy combined with either FP or TP regimen chemotherapy was an effective salvage treatment. Younger age, treatment with the TP regimen and an irradiation dose ≥60 Gy might improve the patients’ treatment outcome.

Locally advanced cancer of the esophagus, current treatment strategies, and future directions

For patients with locally advanced esophageal cancer no clear standard of care exists. Notwithstanding several negative phase III studies the data provide support for so-called trimodality treatment and this is probably the most common approach. Even the role of surgery has been questioned. These alternative approaches are set against a changing epidemiological background whereby adenocarcinoma has become the predominant tumor type, at least in the western world. In recent times an emphasis has been placed on the better selection of patients, predominantly based on data that shows a markedly improved survival in those who exhibit a response to neo-adjuvant therapy. In this article we review the major studies and discuss new approaches to the management of patients with locally advanced cancer of the esophagus.

Esophageal carcinoma advances in treatment results for locally advanced disease: review

The treatment results of patients with locally advanced esophageal carcinomas have evolved since the publication of the first trial of concurrent mitomycin C and 5-fluorouracil with radiotherapy (RT) in 1983. Subsequent studies refined and improved on the concurrent chemotherapy (chemo) with administration of cisplatin and 5-fluorouracil infusion (PF). Chemo (PF) before surgery improved overall survival (OS) in those patients in most of the randomized trials and in meta-analyses. Two courses of PF concurrent with irradiation followed by additional two courses of PF were superior to RT alone without surgery for both groups. Concurrent chemoradiotherapy followed by surgery was found to have statistically improved OS as compared with surgery only in randomized trials and meta-analyses. In most of these studies, it was found that those patients with pathologic complete response to the initial treatment(s) did better than those who had no improvement at all. Current treatment outcome for these diseases is disappointing; newer strategies including induction chemo with the optimal combination, proper dosage of each drug, and proper number of courses before concurrent chemoradiotherapy; improvement in RT; and immunotherapy with or without subsequent surgery are exciting and definitely need to be investigated in prospective randomized trial(s).

Comparison Between Concurrent Chemoradiation Followed by Surgery vs. Surgery for Locally Advanced Cancer of Esophagus

Surgery is an accepted standard in the treatment of localized stage cancer of esophagus. But the ideal approach for locally advanced lesions still remains unknown. Patients with locally advanced lesions (cT3-4N1M0) on the basis of CT chest were subjected either to primary surgery or to preoperative chemoradiation followed by surgery. Major postoperative complications (mortality, anastomotic leak and recurrent laryngeal nerve palsy) did not differ in either arm (P = not significant). Complete pathological response was achieved in 31.2% cases in multimodality arm. Four year overall survival was 10% for whole group. Median survival was 14 months and 20 months in surgery and multimodality arm, respectively (p = .288). In multimodal arm, there was significant survival difference between complete responders and nonresponders (p = .02). For locally advanced lesions, surgery alone gives poor outcome and preoperative chemoradiation followed by surgery should be considered for complete responders.

Utility of preoperative chemoradiotherapy for advanced esophageal carcinoma

BACKGROUND AND AIMS

The most effective treatment would be neoadjuvant chemoradiotherapy (NACRT) plus surgery with three-field lymphadenectomy, if tolerability and complications are acceptable. The aim of this prospective study was to evaluate the tolerability of NACRT+ systematic three-field lymphadenectomy.

METHODS

A total of 127 cases of advanced esophageal carcinoma were objected, among which 32 had NACRT, being the cases suspected to cT3-T4 or, < cT3 with multiple lymph node metastasis. ≥ T2 of 95 cases were treated by surgery alone (NACRT [-] case). The effect of NACRT was evaluated by histological examination and corrected with the clinicopathologic factors, including postoperative prognosis. After reports JCOG9907, we treated eight cases with neoadjuvant chemotherapy at stages II and III. We examined Musashi-1 staining for these eight cases.

RESULTS

Histological good response to NACRT group showed good prognosis. Lymph node metastasis is a predictive factor for prognosis. In this additional study, Musashi-1 was positive after neoadjuvant chemotherapy in three cases. The histological response was grade 1 in all of them and recurrence was observed within a short period of time. Two cases of grade 3 were negative staining to Musashi-1 and showed no recurrence.

CONCLUSIONS

This study shows that NACRT plus surgery with three-field lymphadenectomy is a feasible therapeutic approach for the cases with multiple lymph node metastases. Prognosis was significantly better in cases with marked histological improvement. It is important to find the predictive factors of histological improvement. Musashi-1 might be a candidate maker for histological response and prognosis, and further studies are needed to prove it.

Transthoracic oesophagectomy with lymphadenectomy in 100 oesophageal cancer patients: multidisciplinary approach

OBJECTIVES Analysis of the results on the treatment of esophageal cancer by transthoracic esophagectomy by a multidisciplinary team of surgeons and oncologists. METHODS Between January 1990 and December 2009, 100 consecutive patients underwent transthoracic esophagectomy. Data were collected prospectively and clinical, pathological and histological features of the tumors were analyzed as well as the results of postoperative morbidity and mortality. RESULTS The average patient age was 55 years (range 31- 83 years). In 59 cases the tumor was located in the lower third and in 41 cases in the middle third. Forty-six patients had adenocarcinoma and 54 squamous cell carcinoma. In 54 cases radio-chemotherapy was planned preoperatively. Classifi cation according to pathological tumor stage was: stage 0 in 21 patients, stage I in 10 patients, stage IIa in 28, stage IIb in 9, stage III in 21 and stage IV in 11. The mean number of lymph nodes examined was 14 (range 0-28). Hospital mortality occurred in 4 cases and postoperative complications in 29 patients (33%). The most frequent postoperative complication was pulmonary complications in 17 cases. The average hospital stay was 15.2 days (range 10-40 days) CONCLUSIONS The results of esophageal cancer have been improved in recent years due to the formation of multidisciplinary teams in this pathology. In our study we have shown that the results obtained with the transthoracic technique for cancer of the esophagus are within the ranges reported in the literature for teams with high prevalence of the disease.

Recursive partitioning analysis for new classification of patients with esophageal cancer treated by chemoradiotherapy

BACKGROUND

The 7th edition of the American Joint Committee on Cancer staging system does not include lymph node size in the guidelines for staging patients with esophageal cancer. The objectives of this study were to determine the prognostic impact of the maximum metastatic lymph node diameter (ND) on survival and to develop and validate a new staging system for patients with esophageal squamous cell cancer who were treated with definitive chemoradiotherapy (CRT).

METHODS

Information on 402 patients with esophageal cancer undergoing CRT at two institutions was reviewed. Univariate and multivariate analyses of data from one institution were used to assess the impact of clinical factors on survival, and recursive partitioning analysis was performed to develop the new staging classification. To assess its clinical utility, the new classification was validated using data from the second institution.

RESULTS

By multivariate analysis, gender, T, N, and ND stages were independently and significantly associated with survival (p < 0.05). The resulting new staging classification was based on the T and ND. The four new stages led to good separation of survival curves in both the developmental and validation datasets (p < 0.05).

CONCLUSIONS

Our results showed that lymph node size is a strong independent prognostic factor and that the new staging system, which incorporated lymph node size, provided good prognostic power, and discriminated effectively for patients with esophageal cancer undergoing CRT.

The effect of neoadjuvant chemoradiotherapy on airway colonization and postoperative respiratory complications in patients undergoing oesophagectomy for oesophageal cancer

Respiratory complication is one of the important postoperative complications of oesophageal cancer. The aim of this study was to evaluate whether neoadjuvant chemotherapy before surgery is effective for postoperative respiratory complications. In this study, patients with oesophageal cancer were divided into two group: one with neoadjuvant therapy and the other without neoadjuvant therapy. Before surgery, they all underwent bronchoscopy and bronchoalveolar lavage. We evaluated respiratory complications and the effects of preoperative neoadjuvant therapy. Forty patients (M/F = 23/17 and mean age 61 years) were enrolled in this study. Twenty-two cases had cancer in the middle part and 18 in the lower part of the oesophagus. Significant correlation was observed between the number of positive micro-organism and difficulty in weaning and receiving neoadjuvant therapy. But no significant correlation was found between neoadjuvant therapy and respiratory complications.

Phase II trial of preoperative chemoradiotherapy with oxaliplatin, cisplatin, and 5-FU in locally advanced esophageal and gastric cancer

BACKGROUND

Based on a phase I study showing the feasibility of combining of oxaliplatin, cisplatin, and 5-fluorouracil (5-FU) (OCF) with radiation therapy (RT) in esophageal cancer, the efficacy of this regimen in esophageal, gastroesophageal (GE), and gastric (G) cancer was assessed in this phase II multicenter study.

PATIENTS AND METHODS

Patients with resectable tumors were eligible. Treatment included two cycles of oxaliplatin 85 mg/m(2), cisplatin 55 mg/m(2), and continuously infused 5-FU 3 g/m(2) in 96 h and concurrent RT (45 Gy), followed by surgery after 6-8 weeks. Primary end point was complete pathologic response (pCR).

RESULTS

Forty-one patients were enrolled. Tumor location was esophagus 39% (squamous 10/adenocarcinoma 6), GE junction 32%, and stomach 29%. G3-G4 adverse events included asthenia (27%) and neutropenia (14%). One toxic death occurred. Thirty-one patients (75.6%) underwent surgery (R0 in 94%). Pathologic response was achieved in 58% of patients, with pCR in 50% and 16% of esophageal and GE/G cancer, respectively. pCR was achieved in 67% of squamous cell carcinoma. Survival: median follow-up, 50.4 months; median progression-free survival and overall survival were 23.2 and 28.4 months, respectively.

CONCLUSION

Preoperative OCF plus RT showed an acceptable toxicity and promising activity especially in squamous cell esophageal cancer.

Complete response to preoperative chemoradiation and survival in esophageal cancer: a pooled analysis of three single-institution phase II trials

This pooled analysis was performed using individual patient data from three phase II trials that included on the whole 113 esophageal cancer treated preoperatively with chemoradiotherapy (CRT), in order to analyze the efficacy and survival outcomes according to the achievement of the pathologic complete response (pCR). Thirty-nine patients were treated with 5-fluorouracil/cisplatin and RT (40 Gy), 33 patients received paclitaxel/cisplatin weekly during weeks 1-6 with and RT (46 Gy), 41 patients were treated with induction bio-chemotherapy with cetuximab and FOLFOX-4 followed by concomitant cetuximab and RT of 50.4 Gy. One hundred and two out of 113 resected patients were included in the survival analysis. The median overall survival (OS) time for the whole population was 21.5 months. The 12, 24, and 36 months OS rates were 85.4, 45.2, and 33%, respectively. The difference in survival probability between patients with pCR and patients with partial response or stable disease after treatment was significant (P= 0.0002, hazard ratios = 0.21, 95% CI 0.18-0.60). On multivariate analysis, the pathologic response and histology were the only covariates independently associated with OS (P= 0.0157 and P= 0.0212, respectively). In our series, complete responder patients had a significant longer survival probability after treatment when compared to patients with partial response or stable disease.

Bone marrow micrometastases in esophageal carcinoma: a 10-year follow-up study

Detection of bone marrow micrometastases (BMMs) in patients with esophageal carcinoma may indicate a metastatic phenotype. We assessed if the presence of BMMs had adverse prognostic significance in a 10-year follow-up study. Patients undergoing surgery for esophageal cancer were prospectively recruited between February 1999 and August 2000. Bone marrow aspirates were obtained from the iliac crest of patients under general anesthesia at the time of surgery. Immunocytochemical analysis using anticytokeratin antibodies CAM 5.2 and AE1/AE3 was undertaken to determine the presence of BMMs. Union International Contre le Cancer staging was recorded for all patients. Patient follow-up was completed over a 10-year period through analysis of the Northern Ireland Cancer Registry. Forty-two patients (male = 35) were included, with a mean age of 67.2 years (range 39-83). BMMs were detected in 19 patients (45.2%). International Contre le Cancer tumor staging was stage I = 6, stage II = 10, stage III = 24, and stage IV = 2. BMMs were associated with lymphovascular invasion (P= 0.02) and advanced T stage (P= 0.02). Overall, 10-year survival was 21.4% (n= 9), with a median follow-up of 877.5 days (interquartile range 391.5-2546.3). There was no statistically significant difference between the survival of patients with or without BMMs (1451.4 vs. 1431.6 days, P= 0.99). Univariate analysis demonstrated a trend toward decreased survival for patients with positive lymph nodes (P= 0.07), an increased T stage (P= 0.06), and lymphovascular invasion (P= 0.07). Multivariate analysis demonstrated that none of the variables were significant predictors of mortality. Although the presence of BMMs correlates with recognized adverse tumor characteristics in patients with esophageal cancer, micrometastases detected in the bone marrow at time of surgery does not influence long-term survival.

Neoadjuvant radiochemotherapy in adenocarcinoma of the esophagus: ERCC1 gene polymorphisms for prediction of response and prognosis

INTRODUCTION

Neoadjuvant radiochemotherapy (RT/CTx) regimens were primarily designed for treatment of squamous cell carcinoma of the esophagus. Own preliminary results demonstrate that also patients with locally advanced adenocarcinoma of the esophagus may achieve a major response in 30% with a 3-year survival rate of 80%. To identify these patients, ERCC1 (rs11615) gene polymorphisms were analyzed. ERCC1 is a key enzyme of the nucleotide excision and repair (NER) complex to prevent DNA inter- and intra-strand crosslinks.

PATIENTS AND METHODS

Genomic DNA from 217 patients with cT3/4 adenocarcinoma of the esophagus was extracted from paraffin-embedded tissues. Of these patients, 153 underwent neoadjuvant RT/CTx (CDDP, 5-FU, 36 Gy). For analysis of ERCC1 single nucleotide polymorphisms (SNPs), allelic discrimination was performed by quantitative real-time PCR. Two allele-specific TaqMan probes in competition were used for amplification of ERCC1 (rs11615). Allelic genotyping was correlated with histomorphologic tumor regression after neoadjuvant RT/CTx and survival. Major response (MaHR) was defined as <10% vital residual tumor cells (VRTC).

RESULTS

Analysis of tumor regression revealed a MaHR in 56/153 (36.6%) patients with a 5-year survival rate (5-YSR) of 74% (p < 0.001). ERCC1 gene polymorphisms for all patients showed the following expression pattern: ERCC1 polymorphism (rs11615) CC: n = 27 (12.4%), TT: n = 98 (45.2%), C/T: n = 92 (42.4%). ERCC1 polymorphism CT was identified as a predictor for response to the neoadjuvant RT/CTx (p < 0.001). The 5-YSR for patients with C/T genotype was 51%. Contrary to this, the 5-YSR for the group of patients with a CC/TT polymorphism decreased to 34%.

CONCLUSION

Analysis of ERCC1 (rs11615) gene polymorphisms reveals a significant correlation with response and survival in patients with adenocarcinoma of the esophagus treated with a neoadjuvant radiochemotherapy. Single nucleotide polymorphisms of ERCC1 (rs11615) could therefore be applied to further individualize therapy in esophageal cancer.

Choosing the best treatment for esophageal cancer : criteria for selecting the best multimodal therapy

The best multimodal therapy in esophageal cancer comprises neoadjuvant radiochemotherapy in patients with adenocarcinoma or squamous cell carcinoma whereas neoadjuvant chemotherapy is only appropriate for patients with adenocarcinoma. However, the 2-year survival benefit by this induction therapy compared to surgery alone is only 5-9 %. Targeted drugs seem to be promising in order to improve the response rate. The choice of the best multimodal therapy by response prediction seems only to be possible in patients during chemotherapy for adenocarcinoma, whereas during neoadjuvant radiochemotherapy a response prediction by FDG-PET is not possible. The principle item of multimodal therapy is still transthoracic en bloc esophagectomy which should be performed in high volume centers in order to guarantee stable and good results.

Trimodal therapy in squamous cell carcinoma of the esophagus

Patients with ESCC (squamous cell carcinoma of the esophagus) are most commonly diagnosed with locally advanced tumor stages. Early metastatic disease and late diagnosis are common reasons responsible for this tumor's poor clinical outcome. The prognosis of esophageal cancer is very poor because patients usually do not have symptoms in early disease stages. Squamous cell carcinoma of the esophagus frequently complicates patients with multiple co-morbidities and these patients often require interdisciplinary diagnosis and treatment procedures. At present time, neoadjuvant radiation therapy and chemotherapy followed by surgery are regarded as the international standard of care. Meta-analyses have confirmed that this approach provides the patient with better local tumor control and an increased overall survival rate. It is recommended that patients with positive tumor response to neoadjuvant therapy and who are poor surgical candidates should consider definitive radiochemotherapy without surgery as a treatment option. In future, EGFR antibodies may also be administered to patients during therapy to improve the current treatment effectiveness. Positron-emission tomography proves to be an early response-imaging tool used to evaluate the effect of the neoadjuvant therapy and could be used as a predictive factor for the survival rate in ESCC. The percentage proportions of residual tumor cells in the histopathological analyses represent a gold standard for evaluating the response rate to radiochemotherapy. In the future, early response evaluation and molecular biological tests could be important diagnostic tools in influencing the treatment decisions of ESCC patients.