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Resecting an unresectable tumor?

Esophageal cancer is a highly malignant disease. The direct tumor invasion of adjacent organs is a highly advanced disease in patients with thoracic esophageal cancer. This invasive tumor is categorized as T4 in the TNM staging system. Data from Japanese tumor registries indicate that the incidence of clinical stage T4 is 15.2%, second only to clinical stage T3 at 37.6%. The results of esophagectomies in patients with pathological T4 tumors remain poor, with a five-year survival rate of 9.3%. No standard treatment for these T4 tumors is well established, despite the large population of patients with thoracic esophageal cancer. A computed tomographic scan of the chest and abdomen with intravenous contrast medium is used to detect metastatic disease and to establish the depth of tumor invasion. The detection accuracy of aortic involvement or tracheal invasion exceeds 90%, but is not yet 100%. Therefore clinical T4 disease includes tumors that are assessed as absolutely unresectable or as presumably resectable if neoadjuvant therapy is given. At our institution, these presumably resectable tumors are treated as T3.5. Three treatment options are available for patients with locally advanced cancers: definitive chemoradiation therapy (CRT), neoadjuvant CRT followed by surgery, and surgery followed by CRT. Fujita et al. reported a prospective nonrandomized trial in which esophagectomy followed by CRT was compared with CRT followed by esophagectomy. The CRT-first group showed a significantly better five-year survival rate than the esophagectomy-first group (26% vs. 0%, respectively). Definitive CRT and neoadjuvant CRT followed by surgery have been generally used in patients with clinical stage T4 disease.