Definitive Chemoradiotherapy for Oesophageal Cancer — A Promising Start on an Exciting Journey

doi:10.1016/j.clon.2014.06.001

Clinical Oncology

Volume 26, Issue 9, September 2014, Pages 533-540

https://doi.org/10.1016/j.clon.2014.06.001 Get rights and content

Abstract

Despite many advances in the management of oesophageal cancer, survival rates remain poor. Currently there is no clear consensus on the optimum management modality for localised disease. Surgery alone or combined with neoadjuvant chemotherapy or chemoradiotherapy and definitive chemoradiotherapy are all treatment options used for treating selected patient groups throughout the world. This overview discusses the evidence for definitive chemoradiotherapy, its role for certain patient groups and compared with other treatment options and how it has evolved with emerging technologies over recent decades. It highlights some key areas of research for future trials, including more precise treatment delivery, treatment intensification and a possible randomised controlled trial comparing radiation and surgical-based treatment.

Section snippets

Statement of Search Strategies and Sources of Information

A literature search was carried out using Medline. The search strategy was: oesophageal cancer and definitive chemoradiotherapy, or chemotherapy, or radiotherapy, or clinical trials, or meta-analysis.

Previous Studies

RTOG 85-01 was a landmark trial that set the standard of care for dCRT for many years. It showed a survival advantage of adding concurrent chemotherapy to radiotherapy. It compared radiotherapy alone 64 Gy in 32 fractions with concurrent CRT 50 Gy in 25 fractions with two cycles of both concurrent and adjuvant cisplatin and 5-fluorouracil (5-FU) [9]. The 5 year survival data was 27% versus 0% in favour of CRT [3]. Persistent disease and local regional relapse were the main causes of treatment

Recent Studies

In Europe, the use of CRT in the preoperative setting became more widespread after publication of several meta-analyses showing a benefit [21], [22], [23]. The role of planned surgery after CRT has been examined in two randomised trials from France and Germany. Bedenne et al. [12] treated patients with operable thoracic oesophageal cancer (the vast majority of whom had SCC) initially with one of two different CRT schedules (one using a conventional fractionated schedule of 46 Gy in 23 fractions

Technical Developments

Defining the gross tumour volumes (GTV) relies heavily on a range of diagnostic investigations. Endoscopic ultrasound has become a widely used staging investigation for oesophageal cancer [29] and also plays a useful role in tumour delineation [30], [31], [32]. Positron emission tomography (PET) has also become routine practice in the staging of oesophageal cancer [33] and the use of PET in defining the GTV has been investigated by fusing PET images with the radiotherapy planning computed

Ongoing Trials and Future Directions

The concept of dCRT with surgery reserved for an incomplete response is dependent on a reliable assessment of the treatment response. In the absence of a surgical resection specimen, assessment of a complete pathological response is challenging. In the MUNICON phase II trial, an early metabolic response defined by FDG–PET/computed tomography (reduction of >35% in SUV) was shown to predict the histopathological response and survival [64]. Assessing the response with PET is still under

Conclusion

dCRT is a standard of care for patients with oesophageal SCC and should be considered for patients with non-metastatic adenocarcinoma oesophagus who are at a high risk of incomplete resection or surgical morbidity [14]. Although it is acknowledged that the key to major success in reducing deaths from oesophageal cancer probably lies in prevention and earlier diagnosis, it is an exciting period for radiotherapy development. There have been developments in target volume delineation, radiotherapy