Controversial issues in the therapy of oesophageal carcinoma

There are still a lot of controversies regarding treatment strategies in oesophageal carcinoma due to lack of studies with adequate patient numbers and the inclusion of heterogeneous study populations. Some important news came from the CROSS trial regarding the value of neoadjuvant chemoradiation (CRT). Patients with resectable tumours were randomised to receive surgery alone or weekly administration of carboplatin and paclitaxel for 5 weeks and concurrent radiotherapy. The overall survival in this well-powered study was significantly improved with neoadjuvant CRT resulting in a hazard ratio of 0.657. The control arm with surgery alone showed an exceptional good prognosis with a very low postoperative mortality rate of 4 % only. Also the neoadjuvant therapy showed very good tolerability, the postoperative mortality rate was not increased after neoadjuvant CRT. Only two randomised trials investigated the value of neoadjuvant CRT vs. chemotherapy (CT) in adenocarcinomas of the oesophago-gastric junction (EGJ). Both showed a non-significant trend in favour of neoadjuvant CRT, but both trials included only a limited number of patients. The value of an induction chemotherapy before CRT is still unproven, even if there are several arguments for it and it is daily practice in a lot of centres. Another remaining controversy exists about those patients having achieved a complete response to CRT. Does surgery play a role for the curative therapy of these patients or not? Also this issue is discussed in this review.