Esophageal Cancer: Current Diagnosis and Management

In a prospective nonrandomized study of 13 patients with polyflex stents (polyester mesh stents covered in a silicone membrane) placed prior to neoadjuvant therapy, similar improvements with dysphagia scores were observed after stent placement [70]. In the study, the mean baseline dysphagia score at the time of stent placement was 3. Dysphagia scores were subsequently obtained at 1, 2, 3, and 4 weeks after stent placement and were 1.1, 0.8, 0.9, and 1.0, respectively ( P = 0.005, P = 0.01, P = 0.02, and P = 0.008, respectively). There were no episodes of bleeding or esophageal perforation. Immediate complications from stenting included chest discomfort, seen in 12 of the 13 patients. Stent migration occurred at some point in 6 of 13 patients, although not all patients with a migrated stent required stent replacement. Again, it was thought that the stent migration could be a sign of tumor response to neoadjuvant therapy.

Surgery

Surgery is an essential part of treatment of esophageal cancer [3,71]. Transthoracic, transhiatal, and radical (en bloc) are the 3 different basic approaches for esophagectomy [3]. Because it does not require a thoracotomy, the transhiatal approach has a theoretical advantage of decreased morbidity and mortality, although several studies have shown no differences in outcome between the transthoracic and transhiatal approach [3,72,73]. In a study by Chang et al comparing the transhiatal to the transthoracic approach, the 5-year survival was higher for patients undergoing transhiatal versus transthoracic esophagectomy (30.5% vs. 22.7%, P = 0.02) [73]. However, after adjusting for differences in tumor stage and patient and provider factors the survival advantage was no longer statistically significant (adjusted HR for mortality, 0.95; 95% CI, 0.75 to 1.20).

Adjuvant Therapy

Despite the benefits of chemoradiation as a neoadjuvant treatment, the data for chemoradiation as adjuvant therapy after resection is lacking in most clinical situations [74].

Metastatic Disease

Between 25% and 40% of esophageal cancer patients will present with metastases to liver, bone, and lung or widespread nodal metastases [61].Improvement of quality of life is a major goal in patients with unresectable disease. Patients with nonsurgical esophageal cancer who have an estimated life expectancy of greater than a few weeks are recommended to have concurrent chemoradiotherapy as most patients have symptomatic obstructive disease and dysphagia [62]. A study by Harvey et al examined the palliative benefit of chemoradiotherapy on dysphagia versus toxicity in patients with invasive esophageal carcinoma [75]. The study found that treatment was well tolerated, with only 5% of patients failing to complete treatment. The study used the DeMeester (4-point) symptom scores for the assessment of dysphagia. The median baseline score at presentation was 2 (moderate: difficulty with soft food, predominately liquid diet). After chemoradiotherapy, 49% of patients were assessed as having a dysphagia score of 0 (no dysphagia). Of those patients who received chemoradiotherapy, 78% had an improvement of at least 1 grade in their DeMeester dysphagia, while only 14% of patients did not improve with therapy. The median survival for the study population was 7 months, with a 6% treatment-related mortality. Chemoradiation therapy as a primary treatment for dysphagia can take days to weeks to take effect, and can be associated with significant pain, usually from radiation esophagitis.