New Clinical Guidelines Issued for Esophageal Cancer

Roxanne Nelson

July 01, 2013

The Society of Thoracic Surgeons (STS) has released a set of clinical-practice guidelines to assist in the diagnosis and treatment of localized esophageal cancer.

One of the key recommendations is that endoscopy with biopsy is the diagnostic test of choice for esophageal cancer. Another key recommendation is that staging should be done with computed tomography (CT) and positron emission tomography (PET)/CT. The authors also recommend that endoscopic ultrasonography be used for patients who are surgical candidates to determine the locoregional extent of disease.

The guidelines are published in the July issue of the Annals of Thoracic Surgery.

"This is a first attempt on the part of the thoracic surgical community to use evidence-based practices for the evaluation of esophageal cancer patients," write the authors of an accompanying editorial. "It also sets a precedent for the surgeon to play a pivotal role in the assessment and management of patients with this dreaded disease."

"With the emergence of imaging modalities, such as positron emission tomography, and incorporation of minimally invasive surgical techniques, the STS…recognized the need for a series of esophageal-cancer guidelines to help clinicians in practice," said corresponding author Thomas K. Varghese Jr, MD, an associate professor in the department of surgery at the University of Washington in Seattle.

"Diagnosis and staging are critical steps in the decision-making process for selection of optimal therapy and hence a natural fit to be the first guidelines of this series," he said in a statement.

Key Recommendations

For the diagnosis of esophageal cancer, flexible endoscopy with biopsy is the primary method.

Staging:

  • For early-stage esophageal cancer, chest CT is an optional test for staging. For locoregionalized esophageal cancer, CT of the chest and abdomen is a recommended test for staging.

  • For early-stage esophageal cancer, PET is an optional test for staging. For locoregionalized esophageal cancer, PET is a recommended test for staging.

"Quality, research, and patient safety initiatives are vital components of STS efforts to help provide the highest level of care for patients," said Dr. Varghese. "These clinical-practice guidelines were developed as a resource for the healthcare team to help with these missions, advocating delivery of evidence-based best practices for all of our patients at all times."

The goals of endoscopy are to determine the presence and location of esophageal cancer and to biopsy any suspicious lesions, the authors write. The location of the tumor relative to the teeth and gastroesophageal junction, the length of the tumor, the extent of circumferential involvement, and degree of obstruction should be noted.

In addition, the location and extent of Barrett's esophagus should be documented, if observed in the patient. More than 1 biopsy should be performed to obtain sufficient material for histology analysis. Esophageal ultrasonography should be used to determine the locoregional extent of disease in patients who are candidates for surgery, but as this modality can be unreliable in diagnosing superficial esophageal cancer, diagnostic endoscopic mucosal resection may need to be considered for a more accurate diagnosis.

The authors note that even with advances in treatment regimens, esophageal cancer still remains one of the most lethal of all cancers, with "a dismal overall 5-year survival rate of less than 15%." The optimal treatment for localized esophageal cancer remains one of the most widely debated topics in oncology, they write, although esophagectomy is considered the gold standard for localized disease.

However, while patients with early localized disease do benefit from surgery, the evidence is increasing that neoadjuvant chemotherapy or radiation therapy, or both, followed by esophagectomy, has a survival benefit in advanced disease, when compared with surgery alone. Thus, the authors note, accurate staging information is critical for deciding upon the most appropriate therapeutic intervention, and the focus of the current paper was to systematically review the literature with regard to the diagnostic workup and staging of esophageal cancer. A total of 80 articles met the inclusion criteria following a literature search and served as the source for the review

In the accompanying editorial, coauthors John D. Mitchell, MD, from the University of Colorado Aurora, and Mark J. Krasna, MD, from the Jersey Shore University Medical Center, Neptune, New Jersey, comment that it is generally accepted that a multidisciplinary approach by all managing physicians early on in the care of these patients may lead to better diagnostic and staging evaluation. Although this strategy is time consuming, it "is better in that all the treating physicians participate in determining the best care for each patient. It is critical that thoracic surgeons remain conversant in the modern technological advances, the newest treatment modalities, and the latest published evidence regarding esophageal malignancy to stay relevant in the multidisciplinary environment."

Future clinical-practice guidelines will cover Barrett's esophagus, the role of multimodality therapy, and the choice of esophageal resection techniques, they conclude.

The authors have reported no relevant financial relationships.

Ann Thorac Surg . 2013;96:346–356.

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