Esophageal Cancer: Current Diagnosis and Management

Other alternatives for palliation of nonresectable esophageal cancer include esophageal stenting with SEMS and brachytherapy. SEMS are effective and safe for palliation of dysphagia caused by primary esophageal tumors, postoperative cancer recurrence, esophagorespiratory fistulae, and tumors near the upper esophageal sphincter [76]. A study looking at the use of esophageal SEMS in cancer found that after SEMS placement, the dysphagia score improved from a mean of 3.6 to 1.6 ( P < 0.001) [75]. The procedure was technically successful in 96% of the patients. In all cases, esophagorespiratory fistulas were occluded. Pain, reflux, and stent migration are the most common complications of esophageal SEMS.

In a study comparing single-dose brachytherapy versus SEMS, the SEMS group had quicker improvement of dysphagia symptoms than the brachytherapy group, but the long-term relief of dysphagia was better after brachytherapy [77]. In addition, SEMS placement had more complications than brachytherapy (33% vs. 21%, respectively; P = 0.02), which was mainly due to an increased incidence of late hemorrhage. However, brachytherapy and SEMS did not differ in terms of median survival ( P = 0.23) or recurrent or persistent dysphagia ( P = 0.81).

Tracheoesophageal fistulas may develop in the setting of a locally advanced tumor, or as a complication of RT or chemoradiotherapy. SEMS can also be used successfully in the palliation therapy for tracheoesophageal fistulas or post-esophagectomy anastomotic strictures [78].

Prognosis

The overall survival for patients with resectable esophageal cancer has improved significantly over the past 30 years; however, more than 50% of patients presenting with esophageal cancer will have unresectable or metastatic disease at the time of presentation [3,39,79].Prognosis is primarily TMN stage–dependent, as patients with early stage cancer limited to the mucosa are expected to have curable disease [3]. Poor prognostic predictors include advanced stage cancer, dysphagia, advanced age, large tumors, more than 10% loss in body mass, and malignant adenopathy [39,80–84].

In 2010, the American Joint Committee on Cancer/International Union against Cancer Staging system looked at the prognosis of 4627 patients who underwent esophagectomy alone without radiation or chemotherapy [3,56]. For stage Tis (tumor in situ or high-grade dysplasia) and 1A cancers, there was an approximate 80% 5-year risk-adjusted survival rate [3,56]. The survival rate was marginally better for esophageal adenocarcinoma than for esophageal SCC. With surgery alone, stage 1B disease had a 5-year survival of 62% with SCC and 64% with adenocarcinoma [3,56]. For patients with stage 2A cancer, the 5-year survival was 55% for SCC and 50% for adenocarcinoma as long as there was not nodal involvement [3,56]. If there was nodal involvement, the survival rate dropped to 40% for stage 2B cancer, 25% for stage 3A cancer, and 15% to 17% for stage 3B to 3C cancer [3,56]. As stated earlier, neoadjuvant chemoradiation helps improve outcomes when compared to surgery alone (see Neoadjuvant Therapy in the Treatment section). Thus, one would expect a slightly better prognosis with neoadjuvant therapy and surgery than the previously stated data for surgery alone. Unfortunately, patients with unresectable or metastatic disease at time of diagnosis have a poor prognosis, with a 1-year survival rate less than 20% [3].