Surgery, radiotherapy, and chemotherapy for esophageal cancer

Operative resection, the standard of care in the radical management of loco regional esophageal cancer, is a major surgical procedure, with a clear lea rning curve. It should be performed by experienced surgeons with a sufficie nt annual volume of procedures to maintain competence. Within specialized u nits esophagectomy can be safely offered to appropriately selected patients of all age groups. So far, the choice of operative approach (transhiatal, limited transthoracic, extended transthoracic) still cannot be based on ran domized data with sufficient discriminating power. To date, the role of pre operative neoadjuvant therapy has not been clearly defined. A metaanalysis of five randomized trials did not confirm a substantial benefit for preoper ative radiotherapy. A large randomized trial failed to show any benefit for preoperative chemotherapy. Improving systemic therapy, probably in combina tion with radiotherapy, remains a high priority for the coming years. The r ecent identification of new, highly active, chemotherapeutic agents shows p romising, albeit preliminary, results. (C) 1999 Lippincott Williams & Wilki ns, Inc.