Esophageal cancer

Epidemiology
16,000 cases/year in US
Male to female ratio = 3:1
Adenocarcinoma is increasing in incidence and has replaced SCC as the most common histology

Squamous cell risk factors
Regional (Caucasus, North China)
Black men
Alcohol
Smoking
Plummer-Vinson syndrome
Nitrate containing foods
Achalasia
Lye injury
Tylosis
Head and neck cancer

Adenocarcinoma risk factors
GERD/Barrett's esophagus
White males

Anatomy
Cervical esophagus: cricopharyngeus muscle (15cm from incisors) to sternal notch (18cm)
Thoracic esophagus: Sternal notch to carina (25cm); risk of TE fistula exists here and bronchoscopy is an essential part of the staging
Distal esophagus: Carina to GE junction (40cm)

Siewert classes (for GE junction region tumors):
-I: More than 1cm above GE junction; higher incidence of mediastinal nodes
-II: Crosses GE junction (1cm above to 2cm below)
-III: Below GE junction (more than 2cm); celiac nodes usually involved

Multiple permutations of therapy (chemo/RT/surgery)
1) Chemo-RT vs RT only: RTOG 8501 (RT to entire esophagus, 50.4Gy+/- cis-5FU chemo
Chemo-RT had a significant improvement in 5-year OS (26 vs 0%) but was associated with a significant increase in acute and late toxicity

2) Neoadjuvant chemo vs. surgery only: no clear benefit to added chemo

3) Neoadjuvant RT vs. surgery only: no clear benefit to added RT

4) Neoadjuvant chemo-RT vs. surgery only: 5 randomized trials
-2 showed survival benefit (Walsh, CALGB)
-Equivocal: Urba, Bosset, Burmeister
-Meta-analysis showed OS, LC benefit

5) Chemo-RT vs. chemoRT + surgery: two trials
-French: worse survival in trimodality arm
-German: surgery improved local control but did not show OS benefit

6) Dose escalation
-Minsky: cis/5FU + 50.4Gy vs. 64.8Gy
High dose arm associated with worse OS, 13 vs. 18 months
All deaths in high dose arm occurred before completion of tx
-Gaspar: cis/5FU + 50Gy + 5Gy x 3 or 20Gy x 1
-Fistula rate was 18% at one year
-Local failure was high at 63%

Fields
GTV + 5 cm sup/inf along the esophagus, 2 to 2.5 cm radially
For distal tumors the celiac axis and gastrohepatic ligament nodes should be included