Modern Multimodal Concepts for Advanced and Metastatic Esophageal Cancer

In case of locally advanced esophageal carcinoma, the clear recommendation for multimodal therapy has been established in the guidelines.This also applies to systemic therapy in the palliative, metastatic situation. Against the background of increasing experience with multimodal concepts and a parallel trend towards more and more personalized tumor therapy, therapy options that go beyond this are increasingly being used. The most recent chapter here is the successful use of antibodies and immune checkpoint inhibitors in the adjuvant, additive or palliative setting. Salvage concepts and the salvage operation are also used. These are efficient options to be able to react surgically from a situation of clinical remission and close observation in case of tumor recurrence. The limited radical surgical procedures with reconstruction according to "Merendino" and the "double tract procedure" with limited resection of the distal esophagus and proximal stomach via abdominal approach are options for high-risk patients or very elderly patients. They show great advantages with regard to the operational stress and - especially the "double tract procedure" - with regard to the quality of life. The oligometastatic situation is also the subject of ongoing studies. Under strict clinical observation, it may make sense not to exclude patients with very limited metastases from a curative concept. Numerous cases of long-term survival encourage this. In the palliative setting, in addition to classic chemotherapy and best supportive care, immunotherapy is also playing an increasingly important role, and here, too, a conversion to a curative concept is possible if the response is good. Palliative esophageal resections in the case of disseminated metastases, infiltration of vertebral bodies, aorta or trachea or main bronchi must be strictly avoided and must unfortunately be described as incurable.