Advances in the curative management of oesophageal cancer

Abstract

The incidence of oesophageal cancer, in particular adenocarcinoma, has markedly increased over the last four decades with adenocarcinoma becoming the dominant subtype in the West, and mortality rates are high. Nevertheless, overall survival of patients with oesophageal cancer has doubled in the past 20 years, with earlier diagnosis and improved treatments benefiting those patients who can be treated with curative intent. Advances in endotherapy, surgical approaches, and multimodal and other combination therapies have been reported. New vistas have emerged in targeted therapies and immunotherapy, informed by new knowledge in genomics and molecular biology, which present opportunities for personalised cancer therapy and novel clinical trials. This review focuses exclusively on the curative intent treatment pathway, and highlights emerging advances.

Fig. 1. Overview of the staging of early oesophageal cancers based on their depth of invasion.

Low-grade and high-grade dysplasia are confined to the epithelium. T1a tumours are separated based on their depth of invasion (m1-3). T1b tumours invade into the submucosal layer and are further subdivided based on depth of invasion (sm1-3).

Fig. 2. The Paris endoscopic classification system describes the lesions as protruding, excavated or flat (non-protruding, non-excavated).

This system has not been validated as a prognostic tool in Barrett’s oesophagus but studies suggest that sessile and depressed lesions are more likely to contain invasive cancer, with IIa and IIb lesions at higher risk of associated invasive malignancy.

Fig. 3. Key ongoing trials of perioperative and neoadjuvant therapy for oesophageal adenocarcinoma.

FLOT fluorouracil, leucovorin, oxaliplatin and docetaxel, CROSS paclitaxel, carboplatin and 41.4 Gy/23 fractions, EOX epirubicin, oxaliplatin, capecitabine, EC(O)F(X) epirubicin, cisplatin (or oxaliplatin), fluorouracil (or capecitabine).