I. Preface
Advanced esophageal cancer is still a malignant tumor with poor prognosis and a long-term survival rate of 5%-20%.1 According to statistics, there were about 37,970 new cases of upper gastrointestinal tract tumors and 25,160 deaths in the United States in 2008. Whereas 50% of advanced esophageal cancers have metastatic lesions, less than 60% of patients can undergo radical resection, and regional lymph node metastases are found in about 70%-80% of surgical resection specimens, clinicians are often faced with advanced, incurable patients with primary esophageal cancer. How to make this group of patients achieve immediate and long-term tumor control, improve quality of life and prolong survival? Ma Ning, Department of Medical Oncology, Henan Provincial People’s Hospital
In the treatment of advanced metastatic esophageal cancer, palliative chemotherapy has not shown a significant survival advantage because of the lack of systematic randomized clinical trials.2 This reinforces the need for us to evaluate how to select chemotherapeutic agents in palliative care through evidence-based medical analysis.3 A 2010 retrospective analysis3 compared the advantages and disadvantages of BSC versus chemotherapy in advanced metastatic esophageal cancer. Among the many drugs, cisplatin, 5-fluorouracil, and paclitaxel were highly effective and well-tolerated. Drug application rates4PTX (37.1%), NVB (27.2%), TXT (24.2%), CBP/PTX (31.4%), and CDDP/IRI (28.6%). New biologic agents such as cetuximab, trastuzumab, erlotinib, and bevacizumab may enhance radiotherapy efficacy and systemic micrometastasis targets5.
In this paper, we summarize and analyze the application of chemotherapeutic agents in the treatment of advanced progressive/metastatic esophageal cancer to discuss the impact of various treatment modalities on survival and how to determine the selection of agents that can achieve high pCR in the optimal modality by molecular prediction.
Fourth, the status of multiple treatment modalities in the treatment of advanced esophageal cancer67-71 has been established in the last 20 years, and the standard model of diagnosis and treatment of esophageal squamous carcinoma has helped to clearly define which patients are suitable for surgery and which patients are suitable for comprehensive treatment through a more accurate tumor staging system. The neoadjuvant treatment based on tumor response rate helps to define more patients who benefit from neoadjuvant treatment, so that some patients do not miss the best opportunity for surgery due to poor benefit from neoadjuvant treatment. 2009 Rebollo and his team concluded that PET-CT seems to be the best way to define response or non-response to neoadjuvant treatment in advanced esophageal cancer, however, a large number of recent clinical trials have shown that the efficacy of multidisciplinary combination therapy after long-term follow-up is still less than 20%. efficacy remains below 20%. In short, surgery remains the best option for resectable patients with adequate organ function; despite multiple arguments that preoperative chemoradiotherapy/preoperative chemotherapy reduces tumor pathologic staging and especially increases the chance of feasible R0 resection, high postoperative morbidity and lethality remain issues that must be considered by both physicians and patients; patients surviving >3 years after neoadjuvant chemoradiotherapy have shown a reduction. Future trial directions should continue to evaluate the optimal drug and appropriate dose of combined radiotherapy in multiple treatment modalities to reduce the risk of high postoperative morbidity and mortality. The effect of neoadjuvant chemoradiotherapy on tumor response rate and RO resection rate needs to be evaluated by more effective markers, as pCR and R0 resection rate are independent positive predictors of ESCC. V. Molecular markers for predicting the effectiveness of esophageal cancer treatment72-74 The MAGIC trial showed that perioperative treatment significantly improved patients’ 5-year postoperative survival and reduced the risk of death by 25% relative to patients undergoing surgery alone. The objective responsiveness of tumors is evaluated mainly by the TNM staging system, and reducing tumor stage helps to increase patient survival.The corresponding relationship between reduced stage and increased survival was also shown in the MRC OEO2 trial.Mandard investigated the predictive/prognostic factors of esophageal cancer (mainly containing squamous esophageal cancer) to cytotoxic chemotherapeutic agents.Mandard analyzed the TRG system (tumor regression), which is divided into 5 grades, TRG1 no tumor residual, TRG2 most of the residual tissue confined to the submucosa and a small portion of the supramucosa, TRG3 most fibrosis with a few tumor cells remaining, TRG4 tumor tissue divided by fibrous tissue, and TRG5 almost all tumor tissue (no response). Studying 93 patients, TRG1-3 was a better predictor of DFS than TRG4-5 (p < 0.001). Existing clinical trials do not exclude that neoadjuvant therapy increases survival after surgery, only that the debate focuses on how to respond to the toxicity of chemoradiotherapy. Therefore, this article reviews the role of biological predictors in esophagogastric cancer to guide chemotherapeutic drug selection.