**Multimodal Treatment for Cancer of the Esophagus**

**Multimodal Treatment for Cancer of the Esophagus**

DOI: 10.5772/intechopen.70991

Lucian Mocan, Ofelia Mosteanu, Teodora Pop, Lucia Agoston-Coldea, Cornel Iancu, Teodora Mocan and Furcea Luminita Lucia Agoston-Coldea, Cornel Iancu, Teodora Mocan and Furcea Luminita Additional information is available at the end of the chapter

Lucian Mocan, Ofelia Mosteanu, Teodora Pop,

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.70991

#### **Abstract**

There are about 500,000 new cases of cancer of the esophagus and 400,000 esophageal cancer-related deaths recorded annually around the world. The disease is three to four times more frequent in men than in women, being the sixth most common cancer and the fifth most frequent cancer-related death among men. The prognosis of esophageal cancer is quite poor, despite advances in surgical procedures (two-field and three-field lymph node dissection) and perioperative management, which is still controversial. The use of chemotherapy and radiotherapy in combination with surgery might be a new approach for future treatment. Progress in optical technology has led to the development of a new minimally invasive surgical approach for the treatment of esophageal cancer, namely esophagectomy.

**Keywords:** esophageal cancer, chemotherapy, surgery, radiotherapy, outcome

#### **1. Introduction**

There are about 500,000 new cases of cancer of the esophagus and 400,000 esophageal cancerrelated deaths recorded annually around the world. The disease is three to four times more frequent in men than in women, being the sixth most common cancer and the fifth most frequent cancer-related death among men [1].

Even though esophageal cancer was not very common in Western populations, the incidence of esophageal adenocarcinoma and its related mortality have increased in the USA and certain European countries [2]. The incidence of adenocarcinomas involving the esophagogastric junction, the distal esophagus and the gastric cardia has recorded a more significant increase [3]. The transition from squamous cell carcinoma to Barrett's metaplasia-associated

adenocarcinoma in Western populations could have been determined by the increase in the incidence of obesity and obesity-induced reflux [4, 5].

There are two main subtypes of the disease, namely esophageal squamous cell carcinoma and esophageal adenocarcinoma. The most common causes of squamous cell carcinoma are tobacco and alcohol, and the most common causes of adenocarcinoma are tobacco, obesity and acid reflux [5]. There has been a major increase in the incidence of adenocarcinoma in North America and Europe, while squamous cell carcinoma is still the most common type of esophageal cancer in Asia [6].

The two subtypes of esophageal cancer have different clinical and biological characteristics. While squamous cell carcinomas occur in the middle or upper third of the esophagus, adenocarcinomas occur in the lower third of the esophagus. Abdominal lymph node metastasis is usually present in adenocarcinomas, and the incidence of cervical or upper mediastinal lymph node metastasis is more frequent in squamous cell carcinomas. Thus, the therapeutic approach is different for each subtype [7].

The prognosis of esophageal cancer is quite poor, despite advances in surgical procedures (two-field and three-field lymph node dissection) and perioperative management, which is still controversial [7]. The use of chemotherapy and radiotherapy in combination with surgery might be a new approach for future treatment. Progress in optical technology has led to the development of a new minimally invasive surgical approach for the treatment of esophageal cancer, namely esophagectomy. Long-term survival in resectable esophageal cancer is also influenced by definitive chemoradiotherapy [8]. Salvage esophagectomy is used in patients with esophageal cancer who were treated with chemoradiation as definitive therapy [9].

Although cancer of the esophagus is among the most common cancers in the world, there are few studies on this malignancy. There have been significant changes in the epidemiology of esophageal cancer in the past 30 years, with a striking increase in incidence in Western populations, where the number of adenocarcinomas has exceeded those of the squamous cell type [6]. On the other hand, squamous cell carcinoma is the most frequent subtype in Asian countries, mainly developing in the middle third of the esophagus, without any dramatic increase in the incidence of adenocarcinoma on this continent. New diagnostic, staging, and therapeutic options have improved survival rates for esophageal cancer.

Early stage adenocarcinoma of the esophagogastric junction (AEG) could be detected based on efficient screening for gastroesophageal reflux disease (GERD) and Barrett's metaplasia, which might be cured using endoscopic ablation or surgery [10].

The infection with *Helicobacter pylori* harboring the cagA gene seems to be associated with a reduced risk of esophageal adenocarcinoma [11, 12].

The potential role of COX-2 inhibitors in the effective chemoprevention of esophageal adenocarcinoma, characterized by COX-2 overexpression, is another aspect to be considered [13]. The types of surgery for cancer of the esophagus are divided based on the complex lymphatic drainage from the esophagus and gastric cardia and their anatomy.
