NEW YORK (Reuters Health) - Patients with potentially curable, locally advanced cancer of the esophagus and gastroesophageal junction should undergo multimodality therapy, according to guidelines from the Society of Thoracic Surgeons.
"For me the main message is to encourage an inter- and multidisciplinary approach to patients with esophageal cancer so that care is not provided without the input of all the disciplines," Dr. Alex G. Little from University of Arizona in Tucson told Reuters Health by email.
Dr. Little and colleagues on The Society of Thoracic Surgeons Workforces on Evidence Based Surgery and General Thoracic Surgery undertook a systematic review of multimodality therapy with a view to making evidence-based recommendations for the treatment of locoregional esophageal cancers.
These patients could include those with stage III disease (who have involved regional lymph nodes) and possibly clinical stage II patients that are at high risk for systemic disease (such as cT3 N0 patients).
Class I recommendations included:
- care in a multidisciplinary setting
- restaging after neoadjuvant therapy to rule out interval development of distant metastases
- esophageal resection after neoadjuvant therapy in patients without metastatic disease in whom surgery can be safely done
The guidelines recommend against endoscopic ultrasound restaging for residual local disease (because of its inaccuracy) and against radiotherapy as monotherapy before resection.
Instead, the panel recommends a PET scan for restaging after neoadjuvant therapy to detect interval development of distant metastatic disease, and neoadjuvant platinum-based doublet chemotherapy alone before resection for patients with locally advanced esophageal adenocarcinoma.
The guidelines endorse neoadjuvant chemoradiation therapy for locally advanced squamous cell cancer and either neoadjuvant chemotherapy or chemoradiation therapy for locally advanced adenocarcinoma.
Finally, patients with adenocarcinoma who have not received neoadjuvant therapy should be considered for adjuvant chemoradiotherapy if they have regional lymph node disease, according to the September 25th Annals of Thoracic Surgery online report.
The authors were careful to note that "despite the widespread enthusiasm for multimodality therapy for esophageal cancer, currently available data are not truly definitive." They say large-scale randomized controlled trials "would be useful in clarifying and identifying the ideal treatment algorithm."
Unfortunately, Dr. Little said, "I know of no prospective studies underway comparing multimodality therapy to a single modality. Probably because everyone is convinced that the multimodality approach is the way to go."
There are some patients for whom Dr. Little would not recommend multimodality treatment. "Patients at the two extremes of extent of disease fit this category," he said. "Those with limited disease (Stage I) can proceed directly to surgery and those with extensive disease (Stage IV) are not candidates for surgery and are treated with chemotherapy and/or radiation therapy only. In the Guidelines we speak of patients with locally advanced disease as appropriate candidates for multimodality therapy."
Dr. Edward Yu from the University of Saskatchewan in Regina, Saskatchewan, Canada recently published a review of esophageal cancer treatment from the radiation oncology point of view. He told Reuters Health by email, "The issue of what order of trimodality therapy (chemoradiation followed by surgery versus surgery followed by chemoradiation) is still less clear. Our center, together with another one from China, is presently investigating this issue in a prospective fashion and hopefully can offer more answers in the near future."
"Postoperative radiation therapy is often very challenging in advanced disease," Dr. Yu said. "Radiation oncologists should not be discouraged for that and in fact we are (one of) the very few centers in the world that handle the postop radiation technology reasonably well."
He added, "The recommendation of use of PET scan post-induction therapy is a great idea to identify patients with good response, and often those will have good prognosis."
SOURCE: http://bit.ly/1Aejci2
Ann Thorac Surg 2014;98:1880-1885.
Δεν υπάρχουν σχόλια:
Δημοσίευση σχολίου