Introduction
Purpose
Responsibilities
Basic principles adopted for the preparation of these guidelines
Choice of treatment and patients’ consent
Level of recommendation
Algorithm for treatment of esophageal carcinoma (Fig. 1)
Epidemiology, present status, and risk factors
Summary
Morbidity and mortality
Present status of esophageal carcinoma in Japan
Risk factors
Diagnosis of esophageal carcinoma
Diagnosis of the stage of carcinoma
Summary
Evaluation of the general condition
Performance status (PS)
PS 0 | Fully active and able to carry out all pre-disease activities without restriction |
PS 1 | Restricted in physically strenuous activities, but ambulatory and able to carry out work of a light or sedentary nature, e.g., light housework and office work |
PS 2 | Ambulatory and capable of all self-care, but unable to carry out any work activities. Up and about more than 50 % of waking hours |
PS 3 | Capable of only limited self-care, confined to bed or chair more than 50 % of waking hours |
PS 4 | Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair |
Pulmonary function tests
Cardiac function tests
Hepatic function tests
Renal function tests
Glucose tolerance test
Other considerations
Endoscopic treatment
Summary
Indications for endoscopic resection
Handling of resected specimens and evaluation of the integrity of treatment
Surgical treatment
Summary
Surgery for cervical esophageal carcinoma
Summary
Surgery for thoracic esophageal carcinoma
Summary
Route | Antethoracic | Retrosternal | Posterior mediastinal |
---|---|---|---|
Advantages | 1. Proximal esophagectomy at a higher level is possible | 1. Proximal esophagectomy at a higher level is possible | 1. This route is the most original anatomic location |
2. The anastomotic technique is simple | 2. Reconstruction length is shorter than in the antethoracic route | 2. The surgical stress is less | |
3. Treatment of anastomotic leakage is simple and safe | 3. The procedure for treatment of anastomotic leakage, if any, is easier than in the case of intrathoracic anastomosis | 3. The frequency of anastomotic leakage is low | |
4. Treatment of carcinoma occurring in the reconstructed organ is easy | 4. Treatment of carcinoma occurring in the reconstructed organ is relatively easy | ||
Disadvantages | 1. The reconstruction length is long | 1. The reconstructed organ may compress the heart | 1. Anastomotic leakage may become critical (particularly, in cases of intrathoracic anastomosis) |
2. The frequency of anastomotic leakage is high | 2. If the sternoclavicular joint part is narrow, pressure necrosis of the reconstructed organ may occur | 2. There may be restrictions to proximal esophagectomy | |
3. The reconstructed organ is likely to be bent | 3. Regurgitation occurs frequently | ||
4. There are esthetic issues | 4. Perforation or severe ulcers may occur | ||
5. Blockage due to bending is apt to occur | 5. Surgery for recurrent carcinoma in the reconstructed organ is difficult | ||
6. Radiotherapy for recurrent disease may be difficult |
Surgery for carcinoma of the esophagogastric junction (abdominal esophageal carcinoma)
Summary
Other surgical treatments
Summary
Perioperative management and clinical path
Summary
Salvage surgery
Summary
Neoadjuvant therapy
Summary
Neoadjuvant chemotherapy
Neoadjuvant chemoradiotherapy
Postoperative adjuvant therapy
Summary
Postoperative chemotherapy
Adjuvant radiotherapy
Chemotherapy
Summary
Proven effective monotherapy drugs
Drug | Dose and schedule | No. of cases | Response rate (%) |
---|---|---|---|
5-FU | 500 mg/m2/day × 5 days | 26 | 15 |
Mitomycin C | 20 mg/m2 every 4–6 weeks | 24 | 42 |
Cisplatin | 50 mg/m2 every 3 weeks | 24 | 25 |
Vindesine | 3–4.5 mg/m2 every week | 23 | 18 |
Docetaxel | 70 mg/m2 every 3 weeks | 48 | 21 |
Nedaplatin | 100 mg/m2 every 4 weeks | 29 | 52 |
Paclitaxela
| 100 mg/m2 every week × 6, 2-week withdrawal | 52 | 44 |
Efficacy in combination therapy
Drug | Histologic type | No. of cases | Response rate (%) |
---|---|---|---|
5-FU + cisplatin | Squamous cell carcinoma | 39 | 36 |
Cisplatin + paclitaxela
| Squamous cell carcinoma/adenocarcinoma | 32 | 44 |
Cisplatin + irinotecanb
| Squamous cell carcinoma/adenocarcinoma | 35 | 57 |
Cisplatin + gemcitabineb
| Squamous cell carcinoma/adenocarcinoma | 32 | 45 |
5-FU + nedaplatin | Squamous cell carcinoma | 38 | 40 |
Radiotherapy
Summary
Definitive radiotherapy
Indications
Target volume
Gross tumor volume (GTV)
Clinical target volume 1 (CTV1)
Cervical esophagus (Ce) | From the midsdle deep cervical lymph nodes [102-mid] to the lymph nodes at the tracheal bifurcation [107] |
Upper thoracic esophagus (Ut) | From the supraclavicular lymph nodes [104] to the middle thoracic paraesophageal lymph nodes [108] |
Middle thoracic esophagus (Mt) | a. From the supraclavicular lymph nodes [104] to the lower thoracic paraesophageal [110] or perigastric lymph nodes b. From the lymph nodes along the recurrent laryngeal nerve [106-rec] and upper thoracic paraesophageal lymph nodes [105] to the lower thoracic paraesophageal [110] or perigastric lymph nodes |
Lower thoracic esophagus (Lt) | From the lymph nodes along the recurrent laryngeal nerve [106-rec] and upper thoracic paraesophageal lymph nodes [105] to the perigastric lymph nodes |
Patients of advanced age or with complications | Only lymph node regions around the primary focus |
Clinical target volume 2 (CTV2)
Planning target volume 1 (PTV1)
Planning target volume 2 (PTV2)
Radiotherapy planning and the irradiation method
Dose fractionation
Intracavitary radiation
Complications
Radiotherapy for symptomatic relief
Chemoradiotherapy
Summary
Radiation dose in definitive chemoradiotherapy
Chemotherapy used in definitive chemoradiotherapy
Author | Target stage | Chemotherapy drugs | Radiation dose | |||
---|---|---|---|---|---|---|
5-FU | Cisplatin | Period × No. of courses | Single dose × No. of sessions | Split | ||
RTOG | T1-4N0, 1M0 | 1000 mg/m2/day × 4 days | 75 mg/m2
| every 4 weeks × 4 | 1.8 Gy × 28 | None |
JCOG9708 | T1N0M0 | 700 mg/m2/day × 4 days | 70 mg/m2
| every 4 weeks × 2 | 2.0 Gy × 30 | 1 week |
JCOG9906 | T1N1M0 or T2-3N0-1M0 | 400 mg/m2/day × 10 days | 40 mg/m2 × 2 | every 4 weeks × 2 | 2.0 Gy × 30 | 2 week |
Ohtsu | T4/M1/LYM | 400 mg/m2/day × 10 days | 40 mg/m2 × 2 | every 5 weeks × 2 | 2.0 Gy × 30 | 2 weeks |
Nishimura | T4M0 | 300 mg/m2/day × 14 days | 10 mg/m2
| every 4 week × 2 | 2.0 Gy × 30 | 1 week |
JCOG0303 | T4/M1LYM | 700 mg/m2/day × 4 days | 70 mg/m2
| every 4 weeks × 2 | 2.0 Gy × 30 | 1 week |
KROSG0101 | Stage II–IVA | 700 mg/m2/day × 5 days | 70 mg/m2
| every 4 weeks × 2 | 2.0 Gy × 30 | 1 week |
Nakajima | Stage II/III | 1,000 mg/m2/day × 4 days | 75 mg/m2
| every 4 weeks × 4 | 1.8 Gy × 28 | None |
Adverse events associated with definitive chemoradiotherapy
Follow-up after therapy
Salvage therapy for local remnant or recurrent lesions after definitive chemoradiotherapy
Diagnosis and treatment of Barrett’s esophagus and Barrett’s carcinoma
Summary
Diagnosis and treatment of double carcinoma (head and neck, stomach)
Summary
Follow-up observation after treatment of esophageal carcinoma
Follow-up observation after endoscopic resection
Follow-up observation after radical surgery
Follow-up observation after definitive chemoradiotherapy
Surveillance for metachronous multiple esophageal carcinomas and multiple carcinomas arising from other organs
Treatment of recurrent esophageal carcinoma
Summary
Treatment of recurrence after endoscopic resection
Treatment of recurrence after radical surgery
Treatment of recurrence in cases showing CR after definitive chemoradiotherapy
Palliative medicine
Summary
Therapeutic efficacy and guidelines in Europe and North America: including the results of prognostic studies based on national registries
Summary
Endoscopic treatment
Surgery
Author | Year | Targeta
| Treatment | No. of cases | Histologic type S/A/O | Resected cases | Treatment-related deaths | 2-year survival (%) | 3-year survival (%) | 5-year survival (%) | MST (month) |
---|---|---|---|---|---|---|---|---|---|---|---|
Bosset | 1989–1995 | Stage I–III, excluding T3N1 | S | 139 | 134/0/5 | 137 | 5 (3.6 %) | About 42 | About 35 | About 25 | 18.6 |
CR + S | 143 | 139/0/4 | 138 | 17 + 1 (12.6 %) | About 48 | About 35 | About 25 | 18.6 | |||
Kelsen | 1990–1995 | Stage I–III | S | 234 | 110/124 | 217 | 13 (5.6 %) | 35 | 19 | 7 | 16.1 |
C + S | 233 | 103/120 | 171 | 5 + 10 (6.4 %) | 31 | 18 | 6 | 14.9 | |||
MRCOCWP | 1992–1998 | Resectable cases | S | 402 | 124/268/10 | 386 | 40 (10 %) | 34 | About 25 | About 15 | 13.3 |
C + S | 400 | 123/265/12 | 361 | 36 + 8 (11 %) | 43 | About 32 | About 25 | 16.8 | |||
Bedenne | 1993–2000 | T3N0-1M0 (Stage II–III) ditto CR cases | CR + S | 129 | 115/14 | 107 | 12 (9.3 %) | 39.9 | 16.4 | ||
CR + C | 130 | 115/15 | 1 | 1 (0.8 %) | 35.4 | 14.9 | |||||
Burmiester | 1994–2000 | Stage I–III, excluding T4 | S | 128 | 50/78/0 | 110 | 6 (5.4 %) | 39.8 | 28.1 | 14.8 | 19.3 |
CR + S | 128 | 45/80/3 | 105 | 5 (4.7 %) | 45.3 | 32.8 | 16.4 | 22.2 | |||
Stahl | 1994–2001 | T3-4N0-1M0 | S | 86 | 86/0 | 51 | 11 (12.8 %) | 39.9 | 31.3 | 16.4 | |
CR + S | 86 | 86/0 | 0 | 3 (3.5 %) | 35.4 | 24.4 | 14.9 | ||||
Japan Esophageal Society | 2002 | All resected cases | S + α | 1518 | 41 (4.5 %)b
| 62.2 | 53.6 | 44.1 | About 44 | ||
Stage I | S + α | 361 | 88.5 | 82.7 | 71.2 | About 53 | |||||
Stage IIA | S + α | 290 | 66.6 | 60.7 | 49.2 | About 46 | |||||
Stage IIB | S + α | 211 | 64.9 | 55.7 | 42.8 | About 20 | |||||
Stage III | S + α | 494 | 44.4 | 33.7 | 27.7 |