Towards an optimal treatment strategy for patients with oesophageal cancer

he worldwide incidence of oesophageal cancer is increasing. Adenocarcinoma, associated with gastroesophageal reflux disease, Barrett's oesophagus, obesity, male sex and white race, is the most rapidly increasing type of tumour in many Western countries [1], originating in the lower third of the oesophagus or bridging the gastroesophageal junction. Squamous carcinoma, associated with tobacco and alcohol abuse, male sex and black race, has been stable or decreasing in incidence, with the majority of tumours located in the upper two thirds of the thoracic oesophagus. Oesophageal cancer, whether squamous cell or adenocarcinoma, has been managed as a single disease entity because the survival prognosis was similar. Most clinical trials included either squamous cell carcinoma only or a combination of the two histologies, such that little was learned about adenocarcinoma as a distinct entity. With the advent of newer multimodality therapeutic approaches and a greater understanding of the molecular and pathologic progression of these two entities, it is now clear that they should be studied separately with the expectation that the therapies and prognosis will diverge [2]. Historically, surgical resection as a single therapy was the standard treatment for localised squamous cell and adenocarcinoma of the oesophagus, with cure rates reported in the range of 10–20%. The question is if surgery alone is still appropriate for oesophageal cancer. In order to evaluate the real impact of multimodality treatment strategies on disease control, and to better plan the most appropriate therapeutic option, our first objective when facing oesophageal cancer should be to reach the most accurate staging. Initially, clinical history, physical exam, blood test and nutritional status evaluation should be routinely performed. Conventional endoscopy with tumour biopsy and barium radiographies (especially useful in case of stenotic lesions) are also mandatory. Endoscopic ultrasound (EUS) is the method of choice for staging T1–T3 tumours and N status, including EUS-guided fine-needle aspiration. In order to rule out infiltration of adjacent structures, distant lymphadenopathies and distant metastases, computed tomography (CT) or magnetic resonance imaging (MRI) are used; however, positron emission tomography (PET) and PET-CT are superior in this respect [3], and should be mandatory to rule out metastatic disease before planning