Skip to main content

Advertisement

SpringerLink
Log in

Endoscopic Management of Esophageal Cancer After Definitive Chemoradiotherapy

  • Review
  • Published:
Digestive Diseases and Sciences Aims and scope Submit manuscript

Abstract

Background

Concurrent chemoradiotherapy (CRT) is a potentially curative non-surgical option for locally advanced esophageal cancer, with pathological complete response (CR) ranging from 13 to 49 %. The rate of persistent and recurrent disease within the esophagus remains high at 40–60 %, and treatment of these tumors may improve disease-free survival. The aim of this review is to assess the efficacy of salvage endoscopic therapies for recurrent esophageal cancer.

Methods

Medline and Embase were searched for relevant studies published in the English-language literature that reported use of endoscopic modalities, including photodynamic therapy (PDT), endoscopic mucosal resection (EMR), and spray cryotherapy, as salvage therapies for esophageal cancer.

Results

A total of 12 studies were identified. In small case series of PDT, CR varied from 20 to 100 %, with 1-, 3-, and 5-year overall survival rates of 65–80, 34–47, and 36 %, respectively. Data from three studies of EMR in squamous cell cancer show CR in 50 % of cases, with 3- and 5-year overall survival of 56–81 and 49 %, respectively. Endoscopic spray cryotherapy has recently been used in this setting with an observed CR of 37.5 %.

Conclusions

Endoscopic salvage therapies are options for those patients with disease limited to the superficial esophageal wall and those who are unfit to undergo salvage esophagectomy. Widespread application of endoscopic salvage therapies is limited by the lack of awareness and guidelines for endoscopic surveillance post-CRT and limited data on the effectiveness of endoscopic therapies.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Abbreviations

CR:

Complete response

CRT:

Definitive concurrent chemoradiotherapy

CT:

Computed tomography

EMR:

Endoscopic mucosal resection

EUS:

Endoscopic ultrasound

FDG:

Fluoro-2-deoxy-D-glucose-positron emission tomography

FNA:

Fine needle aspiration

PDT:

Photodynamic therapy

PET:

Positron emission tomography

RFA:

Radiofrequency ablation

SUV:

Standardized uptake value

References

  1. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer. 2010;127:2893–2917.

    Article  PubMed  CAS  Google Scholar 

  2. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin. 2012;62:10–29.

    Article  PubMed  Google Scholar 

  3. Herskovic A, Martz K, Al-Sarraf M, et al. Combined chemotherapy and radiotherapy compared with radiotherapy alone in patients with cancer of the esophagus. N Engl J Med. 1992;326:1593–1598.

    Article  PubMed  CAS  Google Scholar 

  4. Al-Sarraf M, Martz K, Herskovic A, et al. Progress report of combined chemoradiotherapy versus radiotherapy alone in patients with esophageal cancer: an intergroup study. J Clin Oncol. 1997;15:277–284.

    PubMed  CAS  Google Scholar 

  5. Cooper JS, Guo MD, Herskovic A, et al. Chemoradiotherapy of locally advanced esophageal cancer: long-term follow-up of a prospective randomized trial (RTOG 85–01). Radiation therapy oncology group. JAMA. 1999;281:1623–1627.

    Article  PubMed  CAS  Google Scholar 

  6. Chang DT, Chapman C, Shen J, Su Z, Koong AC. Treatment of esophageal cancer based on histology: a surveillance epidemiology and end results analysis. Am J Clin Oncol. 2009;32:405–410.

    Article  PubMed  Google Scholar 

  7. Bollschweiler E, Holscher AH, Metzger R. Histologic tumor type and the rate of complete response after neoadjuvant therapy for esophageal cancer. Future Oncol. 2010;6:25–35.

    Article  PubMed  CAS  Google Scholar 

  8. Courrech Staal EF, Aleman BM, Boot H, van Velthuysen ML, van Tinteren H, van Sandick JW. Systematic review of the benefits and risks of neoadjuvant chemoradiation for oesophageal cancer. Br J Surg. 2010;97:1482–1496.

    Article  PubMed  CAS  Google Scholar 

  9. Gebski V, Burmeister B, Smithers BM, Foo K, Zalcberg J, Simes J. Survival benefits from neoadjuvant chemoradiotherapy or chemotherapy in oesophageal carcinoma: a meta-analysis. Lancet Oncol. 2007;8:226–234.

    Article  PubMed  CAS  Google Scholar 

  10. Tougeron D, Di Fiore F, Hamidou H, Rigal O, Paillot B, Michel P. Response to definitive chemoradiotherapy and survival in patients with an oesophageal adenocarcinoma versus squamous cell carcinoma: a matched-pair analysis. Oncology. 2007;73:328–334.

    Article  PubMed  CAS  Google Scholar 

  11. Bedenne L, Michel P, Bouche O, et al. Chemoradiation followed by surgery compared with chemoradiation alone in squamous cancer of the esophagus: FFCD 9102. J Clin Oncol. 2007;25:1160–1168.

    Article  PubMed  CAS  Google Scholar 

  12. Stahl M, Stuschke M, Lehmann N, et al. Chemoradiation with and without surgery in patients with locally advanced squamous cell carcinoma of the esophagus. J Clin Oncol. 2005;23:2310–2317.

    Article  PubMed  Google Scholar 

  13. van Hagen P, Hulshof MC, van Lanschot JJ, et al. Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med. 2012;366:2074–2084.

    Article  PubMed  Google Scholar 

  14. Walsh TN, Noonan N, Hollywood D, Kelly A, Keeling N, Hennessy TP. A comparison of multimodal therapy and surgery for esophageal adenocarcinoma. N Engl J Med. 1996;335:462–467.

    Article  PubMed  CAS  Google Scholar 

  15. Peng HQ, Halsey K, Sun CC, et al. Clinical utility of postchemoradiation endoscopic brush cytology and biopsy in predicting residual esophageal adenocarcinoma. Cancer Cytopathol. 2009;117:463–472.

    Google Scholar 

  16. Shaukat A, Mortazavi A, Demmy T, et al. Should preoperative, post-chemoradiotherapy endoscopy be routine for esophageal cancer patients? Dis Esophagus. 2004;17:129–135.

    Article  PubMed  CAS  Google Scholar 

  17. Yang Q, Cleary KR, Yao JC, et al. Significance of post-chemoradiation biopsy in predicting residual esophageal carcinoma in the surgical specimen. Dis Esophagus. 2004;17:38–43.

    Article  PubMed  CAS  Google Scholar 

  18. Schneider PM, Metzger R, Schaefer H, et al. Response evaluation by endoscopy, rebiopsy, and endoscopic ultrasound does not accurately predict histopathologic regression after neoadjuvant chemoradiation for esophageal cancer. Ann Surg. 2008;248:902–908.

    Article  PubMed  Google Scholar 

  19. Bates BA, Detterbeck FC, Bernard SA, Qaqish BF, Tepper JE. Concurrent radiation therapy and chemotherapy followed by esophagectomy for localized esophageal carcinoma. J Clin Oncol. 1996;14:156–163.

    PubMed  CAS  Google Scholar 

  20. National Comprehensive Cancer Network (NCCN). Esophageal and Esophagogastric Junction Cancers. 2012. Available at: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp-site.

  21. Rosch T. Endosonographic staging of esophageal cancer: a review of literature results. Gastrointest Endosc Clin N Am. 1995;5:537–547.

    PubMed  CAS  Google Scholar 

  22. Kelly S, Harris KM, Berry E, et al. A systematic review of the staging performance of endoscopic ultrasound in gastro-oesophageal carcinoma. Gut. 2001;49:534–539.

    Article  PubMed  CAS  Google Scholar 

  23. Puli SR, Reddy JB, Bechtold ML, Antillon D, Ibdah JA, Antillon MR. Staging accuracy of esophageal cancer by endoscopic ultrasound: a meta-analysis and systematic review. World J Gastroenterol. 2008;14:1479–1490.

    Article  PubMed  Google Scholar 

  24. Agarwal B, Swisher S, Ajani J, et al. Endoscopic ultrasound after preoperative chemoradiation can help identify patients who benefit maximally after surgical esophageal resection. Am J Gastroenterol. 2004;99:1258–1266.

    Article  PubMed  Google Scholar 

  25. Ribeiro A, Franceschi D, Parra J, et al. Endoscopic ultrasound restaging after neoadjuvant chemotherapy in esophageal cancer. Am J Gastroenterol. 2006;101:1216–1221.

    Article  PubMed  Google Scholar 

  26. Zuccaro G Jr, Rice TW, Goldblum J, et al. Endoscopic ultrasound cannot determine suitability for esophagectomy after aggressive chemoradiotherapy for esophageal cancer. Am J Gastroenterol. 1999;94:906–912.

    Article  PubMed  Google Scholar 

  27. Kalha I, Kaw M, Fukami N, et al. The accuracy of endoscopic ultrasound for restaging esophageal carcinoma after chemoradiation therapy. Cancer. 2004;101:940–947.

    Article  PubMed  Google Scholar 

  28. Jost C, Binek J, Schuller JC, et al. Endosonographic radial tumor thickness after neoadjuvant chemoradiation therapy to predict response and survival in patients with locally advanced esophageal cancer: a prospective multicenter phase ll study by the Swiss Group for Clinical Cancer Research (SAKK 75/02). Gastrointest Endosc. 2010;71:1114–1121.

    Article  PubMed  Google Scholar 

  29. Weber WA, Ott K, Becker K, et al. Prediction of response to preoperative chemotherapy in adenocarcinomas of the esophagogastric junction by metabolic imaging. J Clin Oncol. 2001;19:3058–3065.

    PubMed  CAS  Google Scholar 

  30. Ott K, Weber WA, Lordick F, et al. Metabolic imaging predicts response, survival, and recurrence in adenocarcinomas of the esophagogastric junction. J Clin Oncol. 2006;24:4692–4698.

    Article  PubMed  Google Scholar 

  31. Gillham CM, Lucey JA, Keogan M, et al. (18)FDG uptake during induction chemoradiation for oesophageal cancer fails to predict histomorphological tumour response. Br J Cancer. 2006;95:1174–1179.

    Article  PubMed  CAS  Google Scholar 

  32. Schmidt M, Bollschweiler E, Dietlein M, et al. Mean and maximum standardized uptake values in [18F]FDG-PET for assessment of histopathological response in oesophageal squamous cell carcinoma or adenocarcinoma after radiochemotherapy. Eur J Nucl Med Mol Imaging. 2009;36:735–744.

    Article  PubMed  CAS  Google Scholar 

  33. Brucher BL, Weber W, Bauer M, et al. Neoadjuvant therapy of esophageal squamous cell carcinoma: response evaluation by positron emission tomography. Ann Surg. 2001;233:300–309.

    Article  PubMed  CAS  Google Scholar 

  34. Flamen P, Van Cutsem E, Lerut A, et al. Positron emission tomography for assessment of the response to induction radiochemotherapy in locally advanced oesophageal cancer. Ann Oncol. 2002;13:361–368.

    Article  PubMed  CAS  Google Scholar 

  35. Swisher SG, Maish M, Erasmus JJ, et al. Utility of PET, CT, and EUS to identify pathologic responders in esophageal cancer. Ann Thorac Surg. 2004;78:1152–1160; discussion, p 60.

    Google Scholar 

  36. Cerfolio RJ, Bryant AS, Ohja B, Bartolucci AA, Eloubeidi MA. The accuracy of endoscopic ultrasonography with fine-needle aspiration, integrated positron emission tomography with computed tomography, and computed tomography in restaging patients with esophageal cancer after neoadjuvant chemoradiotherapy. J Thorac Cardiovasc Surg. 2005;129:1232–1241.

    Article  PubMed  Google Scholar 

  37. Barthel JS, Kucera ST, Lin JL, et al. Does Barrett’s esophagus respond to chemoradiation therapy for adenocarcinoma of the esophagus? Gastrointest Endosc. 2010;71:235–240.

    Article  PubMed  Google Scholar 

  38. Swisher SG, Wynn P, Putnam JB, et al. Salvage esophagectomy for recurrent tumors after definitive chemotherapy and radiotherapy. J Thorac Cardiovasc Surg. 2002;123:175–183.

    Article  PubMed  Google Scholar 

  39. Gardner-Thorpe J, Hardwick RH, Dwerryhouse SJ. Salvage oesophagectomy after local failure of definitive chemoradiotherapy. Br J Surg. 2007;94:1059–1066.

    Article  PubMed  CAS  Google Scholar 

  40. Gross SA, Wolfsen HC. The role of photodynamic therapy in the esophagus. Gastrointest Endosc Clin N Am. 2010;20:35–53, vi.

    Google Scholar 

  41. McCann P, Stafinski T, Wong C, Menon D. The safety and effectiveness of endoscopic and non-endoscopic approaches to the management of early esophageal cancer: a systematic review. Cancer Treat Rev. 2011;37:11–62.

    Google Scholar 

  42. Yano T, Muto M, Minashi K, Ohtsu A, Yoshida S. Photodynamic therapy as salvage treatment for local failures after definitive chemoradiotherapy for esophageal cancer. Gastrointest Endosc. 2005;62:31–36.

    Article  PubMed  Google Scholar 

  43. Malhi-Chowla N, Wolfsen HC, Woodward T. The value of photodynamic therapy in the treatment of recurrent esophageal cancer after chemo-radiation therapy. Lasers Surg Med. 1999;24:71.

    Google Scholar 

  44. Wolfsen HC, Hemminger L. Salvage photodynamic therapy for persistent esophageal cancer after chemoradiation therapy. Photodiagn Photodyn Ther. 2006;3:11–14.

    Article  CAS  Google Scholar 

  45. Lecleire S, Di Fiore F, Antonietti M, et al. Nonoperable patients with superficial esophageal cancer treated by photodynamic therapy after chemoradiotherapy have more severe complications than patients treated in primary intent. Am J Gastroenterol. 2008;103:2215–2219.

    Article  PubMed  Google Scholar 

  46. Mashimo Y, Hori K, Yukawa Y, et al. Photodynamic therapy (PDT) as a salvage treatment for local failures at primary site after CRT for esophageal cancer. Dig Endosc. 2010;22:A38.

    Article  Google Scholar 

  47. Nagahisa E, Yano T, Minashi K, et al. Photodynamic therapy for local failure after chemoradiotherapy for patients with unresectable locally advanced esophageal squamous cell carcinoma. Gastrointest Endosc. 2010;71:AB237.

    Google Scholar 

  48. Yano T, Muto M, Minashi K, et al. Long-term results of salvage photodynamic therapy for patients with local failure after chemoradiotherapy for esophageal squamous cell carcinoma. Endoscopy. 2011; 43:657–663.

    Google Scholar 

  49. Yano T, Muto M, Minashi K, et al. Photodynamic therapy as salvage treatment for local failure after chemoradiotherapy in patients with esophageal squamous cell carcinoma: A phase II study. Int J Cancer. 2012;131:1228–1234.

    Google Scholar 

  50. Inoue H, Takeshita K, Hori H, Muraoka Y, Yoneshima H, Endo M. Endoscopic mucosal resection with a cap-fitted panendoscope for esophagus, stomach, and colon mucosal lesions. Gastrointest Endosc. 1993;39:58–62.

    Article  PubMed  CAS  Google Scholar 

  51. Seewald S, Ang TL, Gotoda T, Soehendra N. Total endoscopic resection of Barrett esophagus. Endoscopy. 2008;40:1016–1020.

    Article  PubMed  CAS  Google Scholar 

  52. Momma K, Sakaki N, Yoshida M. Endoscopic mucosectomy for precise evaluation and treatment of esophageal intraepithelial cancer. Endoscopia Digestiva. 1990;2:447–452.

    Google Scholar 

  53. Tada M, Murakami A, Karita M, Yanai H, Okita K. Endoscopic resection of early gastric cancer. Endoscopy. 1993;25:445–450.

    Article  PubMed  CAS  Google Scholar 

  54. Yano T, Muto M, Hattori S, et al. Long-term results of salvage endoscopic mucosal resection in patients with local failure after definitive chemoradiotherapy for esophageal squamous cell carcinoma. Endoscopy. 2008;40:717–721.

    Article  PubMed  CAS  Google Scholar 

  55. Hattori S, Muto M, Ohtsu A, et al. EMR as salvage treatment for patients with locoregional failure of definitive chemoradiotherapy for esophageal cancer. Gastrointest Endosc. 2003;58:65–70.

    Article  PubMed  Google Scholar 

  56. Kondo S, Niwa Y, Tajika M, et al. Effectiveness of endoscopic treatment for residual or recurrent esophageal cancer after chemoradiotherapy. Gastrointest Endosc. 2011;73:AB205.

    Google Scholar 

  57. Halsey KD, Greenwald BD. Cryotherapy in the management of esophageal dysplasia and malignancy. Gastrointest Endosc Clin N Am. 2010;20:75–87,vi–vii.

    Google Scholar 

  58. Cash BD, Johnston LR, Johnston MH. Cryospray ablation (CSA) in the palliative treatment of squamous cell carcinoma of the esophagus. World J Surg Oncol. 2007;5:34.

    Article  PubMed  Google Scholar 

  59. Greenwald BD, Dumot JA, Abrams JA, et al. Endoscopic spray cryotherapy for esophageal cancer: safety and efficacy. Gastrointest Endosc. 2010;71:686–693.

    Article  PubMed  Google Scholar 

  60. Pouw RE, Sharma VK, Bergman JJ, Fleischer DE. Radiofrequency ablation for total Barrett’s eradication: a description of the endoscopic technique, its clinical results and future prospects. Endoscopy. 2008;40:1033–1040.

    Article  PubMed  CAS  Google Scholar 

  61. Shaheen NJ, Sharma P, Overholt BF, et al. Radiofrequency ablation in Barrett’s esophagus with dysplasia. N Engl J Med. 2009;360:2277–2288.

    Article  PubMed  CAS  Google Scholar 

  62. Shaheen NJ, Overholt BF, Sampliner RE, et al. Durability of radiofrequency ablation in Barrett’s esophagus with dysplasia. Gastroenterology. 2011;141:460–468.

    Article  PubMed  Google Scholar 

  63. Kim HP, Bulsiewicz WJ, Cotton CC, et al. Focal endoscopic mucosal resection before radiofrequency ablation is equally effective and safe compared with radiofrequency ablation alone for the eradication of Barrett’s esophagus with advanced neoplasia. Gastrointest Endosc. 2012;76:733–739.

    Article  PubMed  Google Scholar 

  64. Bulsiewicz WJ, Kim HP, Dellon ES, et al. Safety and efficacy of endoscopic mucosal therapy with radiofrequency ablation for patients with neoplastic Barrett’s esophagus. Clin Gastroenterol Hepatol. 2012. doi:10.1016/j.cgh.2012.10.028.

Download references

Acknowledgments

The authors thank James Barthel, MD for his comments and review of the manuscript.

Conflict of interest

Dr. Greenwald is a consultant for and serves on a medical advisory board for CSA Medical, Inc, the manufacturer of a spray cryotherapy device and has received research funding from CSA Medical, Inc. Dr. Khangura has received no research funding and has no conflicts of interest.

Author information

Author notes

  1. Sajneet K. Khangura

    Present address: , 2500 N State St,. Rm. S449, Jackson, MS, 39216, USA

Authors and Affiliations

  1. Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA

    Sajneet K. Khangura

  2. Division of Gastroenterology and Hepatology, University of Maryland Medical Center, Baltimore, MD, USA

    Sajneet K. Khangura

  3. Division of Gastroenterology and Hepatology, Department of Medicine and Greenebaum Cancer Center, University of Maryland School of Medicine, 22 S. Greene Street, Rm. N3W62, Baltimore, MD, 21201-1595, USA

    Bruce D. Greenwald

Authors
  1. Sajneet K. Khangura
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Bruce D. Greenwald
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Bruce D. Greenwald.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Khangura, S.K., Greenwald, B.D. Endoscopic Management of Esophageal Cancer After Definitive Chemoradiotherapy. Dig Dis Sci 58, 1477–1485 (2013). https://doi.org/10.1007/s10620-012-2554-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10620-012-2554-0

Keywords

Search

Navigation