Therapeutic targets
- Cure or improvement of prognosis
- If necessary, also improvement of symptoms, reduction of tumor mass, palliative (palliative treatment).
Therapy recommendations
- The most important therapeutic procedure for squamous cell carcinoma and adenocarcinoma is surgery with the goal of complete removal of the tumor (oral, aboral, and circumferential) and regional lymph nodes.
- For localized adenocarcinomas of the esophagus and esophagogastric (gastrointestinal) junction of category cT2, neoadjuvant chemotherapy (NACT; preoperative chemotherapy) may be performed and continued postoperatively [S3 guideline].
- In operable patients with category cT3 adenocarcinoma of the esophagus or esophagogastric junction and resectable cT4 tumors, perioperative chemotherapy or preoperative radiochemotherapy (RCTX) should be performed [S3 guideline].
- In operable patients with cT2 squamous cell carcinoma of the esophagus, preoperative radiochemotherapy (RCTX) followed by complete resection may be performed [S3 guideline].
- In operable patients with category cT3 squamous cell carcinoma of the esophagus and resectable cT4 tumors, preoperative radiochemotherapy (RCTX) followed by complete resection should be performed [S3 guideline].
- Cytostatic therapy:
- Neoadjuvant chemotherapy (NACT; preoperative chemotherapy) in patients with primary operable tumors of the esophagus or esophageal-gastric junction (median survival doubled from 2 to more than 4 years).
- In the treatment of esophageal cancer, chemotherapy can be used, often in combination with radiotherapy for inoperable tumors and/or distant metastases (radiochemotherapy, RCTX)
- Platinum-based chemotherapy is now the standard of care for squamous cell carcinoma of the esophagus.
- Possible chemotherapy regimens for neoadjuvant preoperative radiochemotherapy (RCTX) are:
- 5-fluorouracil (5-FU)/cisplatin
- Carboplatin/paclitaxel
- Folfox
- Palliative chemotherapy [S3 guideline]:
- Patients with metastatic (formation of daughter tumors) or locally advanced adenocarcinoma of the esophagus that cannot be treated curatively should be offered systemic chemotherapy. The therapeutic goal is to prolong survival and maintain quality of life.
- If HER 2 status is negative, a platinum (oxaliplatin or cisplatin)- and fluoropyrimidine-containing two- or three-drug combination should be used in this regard.
- Second-line systemic therapy should be given to patients with metastatic or locally advanced adenocarcinoma of the esophagus that cannot be treated curatively and who are in adequate general health.
- Second-line therapy may be considered in patients with metastatic or locally advanced squamous cell carcinoma of the esophagus that is not curatively treatable and sufficient general condition.
- “Targeted Therapy: Based on a demonstrated survival benefit, there is an indication for the use of trastuzumab in combination with cisplatin and fluoropyrimidines (5-FU or capecitabine) in HER 2-overexpressing tumors (IHC3+ or IHC2+ and FISH+) [S3 Guideline]Red Hand Letter: Herceptin (trastuzumab), 03/23/2017: monitoring cardiac function before, during, and after treatment with trastuzumab to reduce the incidence and severity of left ventricular dysfunction and congestive heart failure (CHI).
- In advanced stages, palliative therapy (treatment aimed at relieving symptoms rather than curing disease) is given:
- Enteral nutrition, e.g., food supply via a PEG (percutaneous endoscopic gastrostomy: endoscopically created artificial access from the outside through the abdominal wall into the stomach).
- Infusion therapy via a port catheter (port).
- Supplementation of micronutrients
- Pain therapy (according to WHO stage scheme; see below “Chronic pain“).
- See also under “Further therapy”.
No detailed information on active ingredients and dosages is given here, because the therapy regimens are constantly modified.
