Optimizing management strategies for T4b esophageal cancer: the role of TEVAR in multimodal treatment approaches

Abstract

BACKGROUND: T4b esophageal cancer with aortic invasion remains a major therapeutic challenge because treatment-related tumor regression may precipitate aortoesophageal fistula formation and catastrophic hemorrhage. While chemoradiotherapy is the backbone of disease control, the role of thoracic endovascular aortic repair (TEVAR) as prophylaxis or bridge therapy within a multimodal treatment strategy is increasingly recognized. METHODS: This narrative review synthesizes current evidence on the use of TEVAR in T4b esophageal cancer. Relevant clinical studies, reviews and guideline documents were evaluated qualitatively, with emphasis on treatment sequencing, bleeding prevention, resectability and oncologic outcomes. RESULTS: Available retrospective studies and systematic reviews suggest that elective TEVAR may reduce the risk of major bleeding complications and facilitate subsequent esophagectomy in selected patients. Elective TEVAR was associated with higher rates of subsequent esophageal resection and fewer complications than salvage TEVAR. Moreover, elective TEVAR followed by esophagectomy, ameliorates significantly patients survival. These findings support the potential role of elective TEVAR within multimodal treatment strategies, although the available evidence remains predominantly retrospective and is subject to selection bias and heterogeneity in patient selection and treatment. CONCLUSIONS: TEVAR may represent a useful adjunct in the multimodal management of selected patients with T4b esophageal cancer and aortic involvement. In carefully selected patients, elective TEVAR may reduce the risk of catastrophic hemorrhage and facilitate subsequent curative-intent treatment, including conversion esophagectomy, although prospective evidence defining its optimal indications and timing remains lacking.