The therapeutic principle for esophageal cancer is comprehensive treatment with surgery as the cornerstone. The concurrent or sequential application of two or more modalities is defined as comprehensive treatment, which is currently considered to yield better outcomes than monotherapy.
I. Surgical Treatment
Surgery is one of the primary treatment modalities for esophageal cancer and is indicated for patients with stage I, stage II, and selected stage III and IV disease (provided that M = 0, i.e., no distant metastasis). Surgical indications: Patients with cervical lesions < 3 cm, upper thoracic lesions < 4 cm, and lower thoracic lesions < 5 cm have a greater likelihood of undergoing curative resection. The most commonly employed reconstruction is gastric conduit esophagoplasty, although jejunal or colonic interposition may also be utilized.
Surgical approaches are increasingly shifting toward minimally invasive techniques. Thoracoscopic and laparoscopic minimally invasive techniques are being increasingly applied in esophageal cancer surgery. Compared with conventional open surgery, totally endoscopic radical esophagectomy offers reduced trauma, more thorough lymphadenectomy, less postoperative pain, and shorter hospital stays. For very early-stage cases, endoscopic resection (endoscopic submucosal dissection, ESD) may be performed, with a 5-year survival rate exceeding 95%.
Survival rates: For stage 0–I esophageal cancer, the 5-year and 10-year survival rates following surgery can reach 92.6% and 71.6%, respectively. However, the majority of patients are diagnosed at intermediate or advanced stages, with postoperative 5-year and 10-year survival rates of approximately 29% and 21%, respectively. Lymphatic metastasis is a significant prognostic factor: the 5-year survival rates for patients without and with lymphatic metastasis are 45% and 13%, respectively.
Contraindications to surgery: Poor general condition or cachexia; severe cardiac, pulmonary, or hepatorenal dysfunction; evidence of extensive local invasion or perforation (e.g., hoarseness or esophagotracheal fistula); and presence of distant metastasis.
II. Radiotherapy
Radiotherapy plays an important role in the treatment of esophageal cancer; however, the 5-year survival rate with conventional radiotherapy alone is only 8.4%–16.8%. In terms of tumor location, upper thoracic lesions yield better outcomes, while lower thoracic lesions have the poorest prognosis; squamous cell carcinoma responds better than adenocarcinoma. Preoperative radiotherapy can increase resection rates and improve long-term survival, with surgery optimally performed 3–4 weeks after completion of radiotherapy. Postoperative radiotherapy is indicated for residual cancerous tissue following incomplete resection and is generally initiated 3–6 weeks after surgery.
Radiotherapy as a sole modality is primarily used for cervical and upper thoracic esophageal cancer (where surgery is technically challenging, associated with high morbidity, and yields suboptimal outcomes), or for patients with contraindications to surgery.
III. Chemotherapy
Chemotherapy is generally not used as monotherapy for esophageal cancer, but rather in combination with surgery, radiotherapy, or Traditional Chinese Medicine. Esophageal cancer in China is predominantly squamous cell carcinoma, which differs in drug selection from adenocarcinoma, which is more common in Europe and the United States.
Commonly used first-line agents include: fluorouracil (5-FU), capecitabine, oxaliplatin, cisplatin, docetaxel, paclitaxel, irinotecan, and others. Common combination regimens include: carboplatin + paclitaxel (can be combined with radiotherapy), cisplatin + 5-FU (often combined with radiotherapy), ECF (epirubicin + cisplatin + 5-FU, used for gastroesophageal junction tumors), DCF (docetaxel + cisplatin + 5-FU), cisplatin + capecitabine, and others.
Second-line therapy: For esophageal adenocarcinoma, treatment follows the same principles as for gastric and gastroesophageal junction adenocarcinoma. For esophageal squamous cell carcinoma, there is currently no standard second-line chemotherapy regimen; paclitaxel- or docetaxel-based regimens may be considered for patients who have failed first-line platinum- and fluoropyrimidine-based therapy.