ASCO GUIDELINES Bundle

Treatment of Locally Advanced Esophageal Carcinoma

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Key Points ➤ Esophageal cancer is the 6th most common cancer worldwide, with an estimated 450,000 deaths per year. ➤ Multimodality therapy for patients with locally advanced esophageal carcinoma is recommended. • For the subgroup of patients with adenocarcinoma, preoperative chemoradiotherapy or perioperative chemotherapy should be offered. • For the subgroup of patients with squamous cell carcinoma, preoperative chemoradiotherapy or chemoradiotherapy without surgery should be offered. Treatment ➤ Multimodality therapy should be offered to patients with locally advanced esophageal carcinoma. (Strong Recommendation; EB-B-M) Note: Although outside the scope of recommendations for locally advanced esophageal cancer, the Expert Panel recommends that for patients with clinical earlier stage esophageal cancer (T2, N0), surgery alone may be considered after discussion with a multidisciplinary team. Within this group, surgery alone may be more appropriate for patients with low risk cT2NO lesions (i.e. well-differentiated, less than 2 cm), and where there is a sufficient degree of confidence in the results of pretreatment staging. ➤ Preoperative chemoradiotherapy (CRT) or perioperative chemotherapy (CT) should be offered to patients with locally advanced esophageal adenocarcinoma. (Strong Recommendation; EB-B-M) Subgroup considerations: • For the subgroup of patients for whom surgery is not feasible, CRT without surgery is recommended. • Preoperative CT should be considered for patients who are not candidates for radiation or postoperative chemotherapy. • Postoperative complications may be more severe with CRT as compared to CT. Consider the potential for patient tolerance of the addition of RT based on tumor location and other factors. • The addition of radiotherapy is expected to be more beneficial in the setting of less extensive surgery. Adequate quality and extent of surgery includes clear surgical margins and adequate nodal dissection within appropriate nodal fields, e.g. abdominal and thoracic, with a goal of obtaining at least 16 to 18, and preferably greater than 20 lymph nodes. Lymphadenectomy fields and extent of surgery will be affected by tumor location. Detailed recommendations for surgical approach are beyond the scope of this guideline. Note: While outside the scope of the systematic review, the Expert Panel recognizes FLOT as the standard of care for perioperative chemotherapy in esophageal adenocarcinoma. The FLOT regimen includes 4 preoperative and 4 postoperative 2-week cycles of 50 mg/m² docetaxel, 85 mg/m² oxaliplatin, 200 mg/m² leucovorin and 2600 mg/m² fluorouracil as 24- hr infusion on day 1. Where the FLOT regimen is not available or feasible, the Expert Panel suggests cisplatin-fluorouracil (two 3-weekly cycles of cisplatin [80 mg/m² intravenously on day 1] and fluorouracil [1 g/m² per day intravenously on days 1–4]), or a similar platinum- based regimen.

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