Systemic treatment of oesophageal cancer

Most patients with oesophageal cancer present with locally advanced or metastatic disease. In an effort to improve the results of surgery in patients with operable disease, strategies to incorporate radiotherapy and chemotherapy, preoperatively (neoadjuvant) and postoperatively (adjuvant), have been extensively investigated in numerous clinical trials. Meta-analyses of neoadjuvant trials did not demonstrate a survival advantage for neoadjuvant chemotherapy or concurrent chemoradiotherapy. Although local control seems to be improved with neoadjuvant treatment, the currently used chemotherapeutic agents are simply not effective enough to eradicate micro-metastatic disease. Patients who undergo neoadjuvant treatment and achieve a histologically confirmed complete response have a significant better survival than those who do not achieve such a response. Although neoadjuvant chemoradiotherapy is able to induce a higher rate of complete pathological responses compared to neoadjuvant chemotherapy (25-30% vs 5-15%), this advantage is counteracted by a higher incidence of operative mortality. In patients with metastatic disease there is no evidence that chemotherapy (cisplatin, 5-fluorouracil and anthracyclins) improves survival. Several new agents such as taxanes, irinotecan and vinorelbine in combination with cisplatin and carboplatin have shown promising activity in neoadjuvant settings and as palliative treatment of metastatic oesophageal cancer. However, the benefit of these new drugs in the treatment of oesophageal cancer has to be confirmed in randomized trials.     

Combined-modality therapy for locoregional esophageal cancer]

Treatment for patients with esophageal cancer remains unsatisfactory. Although surgery alone or chemoradiotherapy have been generally accepted as reasonable options for patients with locoregional esophageal cancer, 5-year survival rate of either management is about 20%. The limited success of single modality treatment using radiotherapy or surgery has led to the investigation of multimodality therapies, combining chemotherapy, radiotherapy, and surgery. However, the appropriateness of such therapies remains unanswered. A number of prospective randomized trials of trimodality therapy versus surgery alone suggest benefits of combined-modality therapy. Concurrent chemoradiotherapy is an alternative treatment in selected resectable cases to show potential benefits in survival and local control. Patients with complete response following neoadjuvant therapy have consistent, substantial benefits in survival. Pretreatment staging is necessary for standardization of patients undergoing treatment protocols and for outcome evaluation. Biologic markers can be used to predict response to therapy and might allow designation of treatment based on the individual tumor. In the future, clinical trials testing optimal integration of preoperative regimen including new drugs may impact on the prognosis of esophageal cancer.     

Radiation and chemotherapy in the treatment of esophageal cancer.

Patients with esophageal cancer present with a cancer that is locally aggressive in a critical area and that readily metastasizes. Neither surgery nor radiotherapy alone can control local disease, and chemotherapy alone cannot control local or disseminated disease. Combined modalities yield better results. Surgery or radiotherapy is the standard primary treatment. Chemotherapy may help to control local disease and microscopic metastatic disease. Prospective randomized trials indicate that chemotherapy added to surgery and radiotherapy and chemotherapy added to radiotherapy prolong survival.     

Therapeutic strategy for the treatment of postoperative recurrence of esophageal squamous cell carcinoma: clinical efficacy of radiotherapy

We investigated the effectiveness of chemoradiotherapy for the treatment of lymph node recurrence and hematogenous metastasis after esophagectomy for esophageal squamous cell carcinoma. Between 2001 and 2006, 216 patients with thoracic esophageal squamous cell carcinoma had curative esophagectomy. Of those, 23 with lymph node recurrence received chemoradiotherapy (50.0–68.8 Gy). In addition, five patients had isolated recurrences in a distant organ and received chemoradiotherapy (50.0–60.0 Gy). We analyzed outcomes from the radiotherapy for recurrent esophageal cancer. The 1‐, 2‐, and 5‐year survival rates after recurrence for the 23 patients whose lymph node recurrence was treated with chemoradiotherapy were 52, 31, and 24%, respectively, and the median survival time was 13 months. Among the five patients with recurrent tumors in a distant organ, chemoradiotherapy produced a complete response in two patients, a partial response in one patient, and stable disease in two patients, giving an effectiveness rate of 60% (complete response + partial response). Chemoradiotherapy has a beneficial prognostic effect in patients with lymph node recurrence of esophageal squamous cell carcinoma. Chemoradiotherapy for a metastatic tumor in a distant organ may be the treatment of choice in cases where systemic chemotherapy has proven ineffective.     

Photodynamic therapy in cholangiocarcinomas

Symptoms occur late in cholangiocarcinoma and therefore only about half of the patients at the time of diagnosis are candidates for curative surgery. In patients with advanced non-resectable cholangiocarcinoma palliative treatment options are limited. Until now, insertion of endoprostheses for the treatment of cholestasis has been the method of choice. However, tumour growth cannot be influenced and so that prognosis is dismal. Although radiotherapy and chemotherapy are frequently used, prospective, randomized trials showing an improvement in survival time are missing. Encouraging results from prospective, single-arm phase II trials and a randomized trial using photodynamic therapy (PDT) in non-resectable cholangiocarcinoma indicate considerable benefit on survival with a good quality of life. Furthermore, PDT is well tolerated, with only few specific side-effects. This is of great importance in patients with short life expectancy. PDT should therefore be offered to all patients with non-resectable cholangiocarcinoma. However, before initiating PDT or any other palliative measure, a proper staging and a surgical consultation is necessary to avoid missing a curative surgical option.     

Is There a Survival Benefit in Patients With Stage IIIA (N2) Non-small Cell Lung Cancer Receiving Neoadjuvant Chemotherapy and/or Radiotherapy Prior to Surgical Resection: A Systematic Review and Meta-analysis

Optimal management of clinical stage IIIA (N2) non-small cell lung cancer (NSCLC) is controversial. This study is a systematic review and meta-analysis of published randomized control trials of multimodality management strategies for NSCLC.We conducted a comprehensive literature search of the Pubmed, Embase, Medline, and CENTRAL databases for relevant studies comparing patients with stage IIIA (N2) NSCLC undergoing surgery alone, chemotherapy and/or radiotherapy alone, or surgical resection after neoadjuvant treatment with chemotherapy and/or radiotherapy. We estimated hazard ratios, odds ratios (ORs), and 95% confidence intervals (CIs) for survival data.Seven trials involving 1049 patients were included in this study. There was no significant difference in overall survival (OS) or progression-free survival (PFS) in stage IIIA (N2) NSCLC patients who received neoadjuvant chemotherapy or chemoradiotherapy prior to surgical resection compared to those who received neoadjuvant chemotherapy or chemoradiotherapy prior to radical radiotherapy. There was a significant increase in pathological complete remission in the mediastinal lymph nodes in stage IIIA (N2) NSCLC patients who received neoadjuvant chemoradiotherapy prior to surgical resection compared to those who received neoadjuvant chemotherapy (OR 3.61; 95% CI 1.07–12.15; P = 0.04), but no difference in tumor downstaging, OS, or PFS.Neoadjuvant chemotherapy and/or radiotherapy prior to surgical resection do not appear to be clinically superior to neoadjuvant chemotherapy and/or radiotherapy prior to definitive radiotherapy in IIIA (N2) NSCLC patients. Neoadjuvant chemoradiotherapy does not improve survival compared to neoadjuvant chemotherapy alone.     

Therapeutic effectiveness of chemoradiotherapy for carcinosarcoma of the esophagus: two case reports and a review of the literature

Esophageal carcinosarcoma is an extremely rare tumor, and surgery is the mainstay of treatment. We report two patients with carcinosarcoma of the esophagus who received neoadjuvant chemoradiotherapy and underwent curative resection. Patient 1 was a 50-year-old man with a type 2 lesion in the upper thoracic esophagus; clinical stage was T3 or partial T4N1M0. After chemoradiotherapy the tumor and the lymph nodes become smaller, and subtotal esophagectomy was performed. Patient 2 was a 66-year-old man with a protruding lesion in the lower thoracic esophagus. Preoperative chemoradiotherapy was administered, and he had a partial response. However, surgery was postponed because of pneumonia; 11 months later, tumor enlargement was confirmed and we then performed subtotal esophagectomy. The therapeutic role and effectiveness of both chemotherapy and radiotherapy remain unclear. We reviewed 26 previously reported cases of esophageal carcinosarcoma treated by chemotherapy, radiotherapy, or both. These findings suggest that preoperative chemoradiotherapy may be effective for downstaging the primary tumor in patients with advanced esophageal carcinosarcoma.     

Cholangiocarcinoma and the role of radiation and chemotherapy

Cholangiocarcinoma is a rare tumor. Many cases are localized while metastatic disease within the liver and abdomen do occur. There is as yet no standard therapy for advanced bile duct tumors. Radiotherapy and chemotherapy are not curative modalities in this condition but are being assessed adjuvantly following surgery, and as palliative treatment in an attempt to either extend progression-free and overall survival or to palliate symptoms. Advances may be made by: (i) The combined use of radiation and chemotherapy, (ii) High dose conformal radiotherapy, (iii) Novel chemotherapeutic agents. Patients should be given the opportunity to participate in clinical trials.     

Progress in multidisciplinary treatment for esophageal cancer in Japan as reflected in JCOG studies

Changes in the standard treatment for esophageal cancer in Japan are reflected in the history of consecutive studies conducted by the Japan Esophageal Oncology Group (JEOG), a subgroup of the Japan Clinical Oncology Group (JCOG). Following the era of preoperative radiotherapy in the 1970s, the emphasis in surgical adjuvant therapy shifted from postoperative radiotherapy in the 1980s to postoperative chemotherapy including cisplatin as a key drug in the 1990s. Later, the optimal timing for perioperative adjuvant therapy returned to before surgery based on the results of a JCOG study (JCOG9907) that compared preoperative chemotherapy with postoperative chemotherapy in the late 2000s. Next, the clinical question of which is better, preoperative aggressive chemotherapy or preoperative chemoradiotherapy, still needs to be resolved. Concurrent chemoradiotherapy using cisplatin and 5-fluorouracil became a standard non-surgical treatment for esophageal cancer from the early 1990s onwards. Based on the preferable results of definitive chemoradiotherapy for unresectable advanced disease, definitive chemoradiotherapy was considered to be a possible alternative treatment modality in stage I esophageal cancer patients. Therefore, JEOG conducted a phase III study (JCOG0502) to demonstrate the non-inferiority of chemoradiotherapy compared with surgery in patients with stage I esophageal squamous cell carcinoma. If definitive chemoradiotherapy fails in patients with stage II/III esophageal cancer, salvage surgery is now recommended. Therefore, JEOG has initiated a phase II study (JCOG0909) to evaluate the efficacy and safety of this combined treatment modality.     

Adjuvant treatment in biliary tract cancer: to treat or not to treat?

Biliary tract cancer is a rare malignant tumor. There is limited knowledge about biology and natural history of this disease and considerable uncertainty remains regarding its optimal diagnostic and therapeutic management. The role of adjuvant therapy is object of debate and controversy. Although resection is identified as the most effective and the only potentially curative treatment, there is no consensus on the impact of adjuvant chemotherapy and/or radiotherapy on the high incidence of disease recurrence and on survival. This is mainly due to the rarity of this disease and the consequent difficulty in performing randomized trials. The only two prospectively controlled trials concluded that adjuvant chemotherapy did not improve survival. Most of the retrospective trials, which had limited sample size and included heterogeneous patients population and non-standardized therapies, suggested a marginal benefit of chemoradiotherapy in reducing locoregional recurrence and an uncertain impact on survival. Well-designed multi-institutional randomized trials are necessary to clarify the role of adjuvant therapy. Two ongoing phase III trials may provide relevant information.     

Prognostic factors of radiotherapy in patients with node-positive thoracic esophageal squamous cell carcinoma after radical surgery

The aim of this study was to retrospectively analyze and assess the outcomes and prognostic factors of radiotherapy in patients with node-positive thoracic esophageal squamous cell carcinoma after radical surgery. One hundred twenty-six patients with node-positive thoracic esophageal squamous cell carcinoma who had undergone adjuvant therapy (postoperative radiotherapy alone or postoperative sequential chemoradiotherapy without receiving postoperative concurrent chemoradiotherapy) after radical surgery, were retrospectively reviewed from January 1996 to December 2003. Univariate and multivariate analyses were performed using log-rank and Cox proportional hazard models, and survival curves were estimated using the Kaplan-Meier method. The 1-, 3- and 5-year overall survival rates of all 126 patients were 71.4, 39.1, and 22.0%, and disease-free survival rates were 64.3, 36.4, and 21.5%, respectively. Lymph node ratio (the ratio of the number of metastatic lymph nodes to the number of lymph nodes removed, LNR) ≥0.2 ( P = 0.006), pT3 + pT4 ( P = 0.06) and sequential chemoradiotherapy ( P = 0.08) were associated with a poorer survival by univariate analysis. In multivariate analysis, LNR ( P = 0.01, hazard ratio = 0.57, 95% confidence interval, 0.37–0.87) and tumor depth of invasion ( P = 0.03, hazard ratio = 0.62, 95% confidence interval, 0.41–0.96) were the independent predictors of survival. Sequential chemoradiotherapy receded survival tendency without significant difference ( P = 0.09, hazard ratio = 0.64, 95% confidence interval, 0.37–1.08). Therefore, LNR and tumor depth of invasion were the independent prognostic factors of radiotherapy in patients with node-positive thoracic esophageal squamous cell carcinoma after radical surgery. The addition of chemotherapy does not seem to confer a survival benefit.     

Neoadjuvant therapy for resectable esophageal cancer

BACKGROUND: Surgical excision remains the only therapeutic approach with curative potential in patients with localized esophageal cancer. Due to the presence of lymph node metastases upon diagnosis in a large percentage of patients with locally advanced tumors and/or the presence of considerable co-morbidity, only a limited number of patients are amenable to surgery. These facts have prompted us to evaluate approaches including perioperative therapy modalities. METHODS: By means of a computer-supported search (MEDLINE, ASCO Proceedings) as well as a manual literature search, randomized clinical trials and meta-analyses evaluating preoperative therapy plus surgery in patients with resectable esophageal cancer were identified. RESULTS: Twenty-three randomized clinical studies and five meta-analyses were identified. Interpretation--especially of the older studies--however, is hampered by the lack of a stringent application of modern examination techniques allowing for exact specification of tumor stage (resectable/locally advanced) as well as the inclusion of patients with different histological entities (squamous cell/adenocarcinoma), different surgical techniques and the low number of patients. There were no significant differences for the following perioperative therapy modalities regarding tumor-related mortality: preoperative radiotherapy versus postoperative radiotherapy, preoperative and postoperative radiotherapy versus postoperative radiotherapy (higher mortality in preoperative and postoperative radiotherapy arm), preoperative radiotherapy versus surgery, preoperative chemotherapy versus surgery, preoperative and postoperative chemotherapy versus surgery. In terms of 3-year mortality, statistically significant differences could be found for the following therapy modalities: preoperative radiochemotherapy versus surgery (preoperative therapy superior), preoperative chemotherapy versus preoperative radiotherapy (preoperative radiotherapy superior). CONCLUSION: Judging from these data, no clear recommendation for a standard multimodality approach outside clinical studies can be given for patients with resectable esophageal cancer. Neoadjuvant therapy, therefore, can only be recommended in centers with a maximum surgical expertise and in the context of multidisciplinary study protocols.     

Current issues in the treatment of colorectal cancer

For colorectal cancers that are confined to the bowel wall with uninvolved nodes, surgery alone is curative in most patients, and adjuvant treatment is usually not indicated. A combined modality approach for the initial treatment of many rectal and selected colonic carcinomas is based on data that "radical" operations do not necessarily prevent either local regrowth or distant failures and acceptance of a significant palliative but infrequent curative role for irradiation and chemotherapy when such failures occur. Published data for rectal cancer indicates that local recurrence can be markedly reduced by moderate to high dose pre- and post-operative irradiation +/- chemotherapy. For colon cancer, data from pilot trials suggest that post-operative irradiation may reduce local recurrence by stage when compared with surgery alone analyses, but randomized trials are needed. With locally advanced disease, aggressive treatment combinations appear to increase both local control and survival, but much interaction is required between involved physicians.     

食管癌新辅助放化疗对手术及生存率的影响

新辅助化疗常应用于实体肿瘤的手术前或围手术期,常联合应用放疗以提高生存率和治愈率,并对器官加以保护.手术仍是最有效的食管癌单一治疗手段.术前的(新辅助)化疗加放疗虽已经作为治疗食管癌的3种方法中的综合治疗模式存在近20余年,但他是否可作为食管癌的标准治疗模式仍存在争议.本文阐述了新辅助放化疗对食管癌手术及生存率的影响,提出了新辅助放化疗在食管癌治疗中的不足和发展方向.     

Adjuvante und neoadjuvante therapie des rektumkarzinoms

The Consensus Conference of the German Cancer Society (CAO/AIO/ARO, 1.7. 1998) has recently updated recommendations for patients with rectal cancer. Instead of a former reservation regarding the indication of adjuvant therapy for rectal cancer the actual version of the consensus particularly emphasizes the tole of postoperative radiochemotherapy for stage-II/III tumors. This article reviews the most recent and ongoing trials of adjuvant and neoadjuvant therapy of rectal cancer. To avoid local recurrence is the most important aspect in the primary treatment of rectal cancer. In some series, e. g. the results of the Surgical Department of the University of Erlangen, a significant correlation between local control and survival was noted. The final results of the Swedish Rectal Cancer Trial with 1168 randomized patients not only confirmed the potential of radiotherapy to reduce local recurrence-rate, but also demonstrated a significant survival advantage for patients receiving short-course preoperative radiation therapy. Postoperative combination therapy is usual in the United States and in most European countries since the publication of two randomized trials of the Gastrointestinal Tumor Study Group (GITSG) and the North Central Cancer Treatment Group (NCCTG). The survival advantage resulting from an adjuvant radiotherapy with conventional doses and concurrent fluorouracil-based chemotherapy as compared to surgery alone was recently confirmed in a Norwegian trial. Protracted venous 5-fluorouracil infusion should further improve treatment results. Numerous phase-ll studies have demonstrated the efficacy of preoperative radiochemotherapy with high rates of pathological response. Thus, neoadjuvant radiochemotherapy is recommended for patients with locally advanced tumor primarily not amenable to curative surgery. Prospective randomized trials are ongoing to clarify the tole of preoperative versus postoperative combined treatment for patients with resectable rectal cancer. Radiochemotherapy for rectal cancer is recommended as standard treatment outside clinical trials for Stage II/III patients after curative treatment and for patients with T4-tumor prior to surgery. The optimal use of chemotherapy and the sequence of treatment modalities remains to be elucidated.     

Curative treatment for esophageal cancer: Vancouver Island Cancer Centre experience from 1993 to 1998.

OBJECTIVES: To review outcomes after curative treatment for esophageal cancer in the Vancouver Island Cancer Centre from 1993 to 1998. Curative treatments included esophagectomy alone, and chemoradiotherapy with "selective surgery" for patients with post-treatment-positive endoscopic biopsy or less than 75% regression on computed axial tomography scan, or with resectable local recurrence. METHODS: Patients undergoing esophagectomy alone, or primary chemoradiotherapy and "selective surgery" were reviewed. This was a retrospective, nonrandomized, institutional experience. Surgical complication, relief of dysphagia, disease-specific survival rates and prognostic factors were analyzed. RESULTS: Nineteen patients underwent esophagectomy alone. A total of 56 patients underwent primary chemoradiotherapy, of whom 16 had "selective surgery". Relief of dysphagia was similar in both groups of esophagectomy patients. Exploration for "selective surgery" was performed in 12 patients after their first postchemo-radiotherapy endoscopy (two patients had unresectable disease), and in seven for relapse, one of whom died intraoperatively. Overall, the mortality rate due to surgery was 3%. Chemoradiotherapy was not associated with more frequent serious surgical complications. For patients who underwent esophagectomy alone and those who underwent chemoradiotherapy plus selective surgery, the median survival times were 12.9 and 16.4 months, respectively, and the three-year survival rates were 21% and 37%, respectively. Seventeen of 25 patients who underwent chemoradiotherapy and who survived more than two years have not required selective surgery. For the two groups of patients combined, no single prognostic factor for survival was significant in multivariate analysis, but for patients who underwent chemoradiotherapy plus selective surgery, negative endoscopic biopsy was highly significant. CONCLUSIONS: Surgical complication and disease-specific survival rates after primary chemoradiotherapy with selective surgery compare favourably with esophagectomy alone in the curative treatment of esophageal cancer. A prospective, randomized trial is necessary for the definitive evaluation of the strategy of chemoradiotherapy and selective surgery.     

The role of chemotherapy in the treatment of unresectable stage III and IV nonsmall cell lung cancer

Modern platinum-based combination chemotherapy has played a major role in the therapeutic approach to unresectable stage III and IV NSCLC. Randomized phase III trials clearly documented a survival as well as palliative benefit to treatment in patients with stage IV NSCLC who have a good PS (PS 0-1). The optimal therapeutic approach in patients with poor PS (PS 2) has not yet been defined. Recent trials that focused on the elderly suggested that they receive benefits from chemotherapy that are similar to their younger counterparts. The benefit from chemotherapy seems to occur early (initial 3 to 4 cycles) and prolonged therapy is not indicated. Second-line therapy that is administered upon progression was shown to provide survival and palliative benefits. In unresectable stage III NSCLC, the addition of chemotherapy to TRT improves long-term survival and has the potential to cure a minority of patients. Although sequential and concurrent chemoradiotherapy approaches have improved survival in phase III trials, concurrent strategies seem superior in comparative trials. New techniques in radiation therapy, such as three-dimensional treatment planning, may allow safer administration of both modalities concurrently and allow higher doses of TRT to be delivered. In unresectable stage III and stage IV NSCLC, the role of the new "targeted" therapies is currently being defined in several randomized, phase III trials. It is imperative that physicians who care for patients with advanced NSCLC be aware of these trials and attempt to enroll their patients, if possible. It is only through the successful and timely completion of well-designed clinical trials that we will advance our knowledge of improved treatment options for our patients with this disease.     

Preoperative therapy in locally advanced esophageal cancer

Esophageal cancer is an aggressive malignancy associated with dismal treatment outcomes. Presence of two distinct histopathological types distinguishes it from other gastrointestinal tract malignancies. Surgery is the cornerstone of treatment in locally advanced esophageal cancer(T2 or greater or node positive); however, a high rate of disease recurrence(systemic and loco-regional) and poor survival justifies a continued search for optimal therapy. Various combinations of multimodality treatment(preoperative/perioperative, or postoperative; radiotherapy, chemotherapy, or chemoradiotherapy) are being explored to lower disease recurrence and improve survival. Preoperative therapy followed by surgery is presently considered the standard of care in resectable locally advanced esophageal cancer as postoperative treatment may not be feasible for all the patients due to the morbidity of esophagectomy and prolonged recovery time limiting the tolerance of patient. There are wide variations in the preoperative therapy practiced across the centres depending upon the institutional practices, availability of facilities and personal experiences. There is paucity of literature to standardize the preoperative therapy. Broadly, chemoradiotherapy is the preferred neo-adjuvant modality in western countries whereas chemotherapy alone is considered optimal in the far East. The present review highlights the significant studies to assist in opting for the best evidence based preoperative therapy(radiotherapy, chemotherapy or chemoradiotherapy) for locally advanced esophageal cancer.     

Locoregional chemotherapy in pancreatic cancer

BACKGROUND/AIMS: Investigating whether or not locoregional chemotherapy has an effect on survival among patients with pancreatic cancer. The possibility of radical surgical interventions for treatment of cancer of the pancreas is very low. Locoregional chemotherapy is one of the modalities advocated to increase survival of such patients. METHODOLOGY: Twenty-nine patients with cancer of the pancreas underwent surgery in our clinic. Eleven patients were female and 18 were male. Surgical procedures and adjuvant locoregional chemotherapy applied to these patients as well as survival obtained are evaluated and compared to those reported in the literature. RESULTS: Eight of the 9 patients that received curative surgery and adjuvant locoregional chemotherapy are still alive after 5, 6, 7, 7, 9, 12, 13, and 17 months. Seventeen patients with advanced stage pancreatic cancer had palliative diversion procedures. Mean survival was 10.5 months for the seven that received locoregional chemotherapy, but 6.2 months for the 10 patients that did not receive locoregional chemotherapy. Mean survival of 3 patients that had only laparotomy was 2.3 months. CONCLUSIONS: Neoadjuvant or adjuvant locoregional chemotherapy has a beneficial effect on the survival of patients that undergo curative or palliative surgery for pancreatic cancer. However further multicenter trials are necessary.     

Endoprosthetics for malignant esophageal disease

Currently used stents for malignant esophageal strictures include self-expanding metal stents (SEMS), self-expanding plastic stents (SEPS), and biodegradable stents. For the palliative treatment of malignant dysphagia, both SEMS and SEPS effectively provide rapid relief of dysphagia. SEMS are preferred over SEPS as randomized controlled trials have shown more technical difficulties and late migration with plastic stents. Despite specific characteristics of recently developed stents, recurrent dysphagia due to food impaction, stent migration, and both tumoral and nontumoral tissue overgrowths are common. Complication rates are probably also affected by stent “behavior” in the esophagus, with radial and axial forces being important determinants. The efficacy of stents with an antireflux valve for patients with distal esophageal cancer has not convincingly been proven. Concurrent treatment with chemotherapy and radiotherapy seems to be safe and effective, although biodegradable stents have shown disappointing results. It can be expected that removable stents will increasingly be used as bridge to surgery to maintain luminal patency during neoadjuvant treatment.