Curative management of adenocarcinoma of the oesophagus - pro multimodal approach

The incidence rates of adenocarcinoma (AC) of the oesophagus were reported to increase rapidly in the Western Countries, especially within white males . Due to the late appearance of tumour specific symptomes, most of the carc inomas are diagnosed at advanced stages. Because of the majority of the pat ients presenting with lymph node metastases even in localized disease, the long term results with surgery alone are disappointing, Overall Less than 3 5% can he cured and three year survival rates (3-YSR) rarely exceed 25% in patients with locally advanced tumours (T3/4N0-1M0). For these reasons mult imodal approaches have been investigated recently, Preoperative chemoradiat ion seems to be most promising in improving the curative power of the treat ment. Beside a couple of phase II studies, 2 phase III trials proved superi ority of multimodal treatment compared with surgery alone in localized AC ( 1,2) by increasing 3-YSR from about 10% to 30%. These trials were critisize d because of incomplete tumour staging and a possible stratification bias. However, recent phase II studies from the US and from our own group (3,4) c onfirmed the role of preoperative chemoradiation also in properly staged (i ncluding endoscopic ultrasound) locally advanced AC. Both trials showed com plete resection rates of 90% and based on very high local tumour control ra tes of above 90% long term survival reached about 40% in these high risk pa tients. These impressive data were injured by perioperative mortality rates of 15%, which were obviously increased by the preoperative treatment. Thus , preoperative chemoradiotherapy is very likely to increase cure rates in p atients with AC of the oesophagus. To prove this, well designed phase III t rials are warranted.