Treatment
➤ Preoperative CRT or CRT without surgery (definitive CRT) should be
offered to patients with locally advanced esophageal squamous cell
carcinoma. (Strong Recommendation; EB-B-M)
Subgroup considerations:
• Historical studies suggest that in patients who respond completely to CRT, the
addition of surgery may offer minimal benefit. In patients with squamous cell
carcinoma who appear to have a complete response to CRT, the option of surveillance
and salvage surgery upon progression may be considered, where salvage esophagectomy
is practiced. At this time, randomized controlled trials are exploring the question of
surveillance and salvage surgery after CRT compared to planned surgery after CRT.
• In patients for whom radiation is not an option, preoperative CT (without radiation)
may be considered.
• Definitive CRT is recommended for patients with tumors located in the cervical
esophagus; surgery should be considered in the event of persistent or recurrent disease.
• While CRT and surgery are preferred, definitive CRT is an option for patients who
cannot tolerate or choose not to undergo surgery.
Practice Statement
➤ For patients with esophageal squamous cell carcinoma, the decision to
undertake surgery should be considered in the context of shared decision
making, considering age, comorbidities, patient preference, caregiver
support, and other factors. (CB-H)
ASCO Recommendation Update – August 2021
➤ Following neoadjuvant CRT and surgery, nivolumab should be offered
to patients with locally advanced esophageal carcinoma with Eastern
Cooperative Oncology Group status 0-1 who did not experience a
pathological complete response (i.e., with residual disease of at least
ypT1 or ypN1 in resected specimens). (Strong Recommendation; EB-B-M)
Qualifying statements:
▶ Data are not available to support any recommendation for nivolumab following
treatment with perioperative chemotherapy.
▶ A post-hoc analysis showed an HR for disease-free survival of 0.62 (95% CI, 0.46 to
0.83, median DFS 29.4 vs. 10.2 months) in the subgroup of patients with programmed
death-ligand 1 (PD-L1) combined positive score (CPS) of at least 5 (n=371) and 0.89
(95% CI, 0.65 to 1.22, median DFS 16.3 vs. 11.1 months) in the subgroup of patients
with PD-L1 CPS of less than 5 (n=295). This exploratory analysis suggests that future
studies may define biomarkers, such as PD-L1 CPS, and/or a subgroup that will benefit
from adjuvant nivolumab.
