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Esophageal cancer

What's new

The European Society of Medical Oncology (ESMO) has released an interim update on the treatment of esophageal and esophagogastric junction cancer. Perioperative chemotherapy with 5-fluorouracil/leucovorin/oxaliplatin/docetaxel (FLOT) followed by surgery is recommended for resectable, locally advanced esophageal or esophagogastric junction adenocarcinoma, with neoadjuvant chemoradiotherapy reserved for patients unsuitable for FLOT chemotherapy, based on the Neo-AEGIS, ESOPEC, and TOPGEAR trials. Tislelizumab-based chemotherapy is recommended as a first-line option for advanced esophageal squamous cell carcinoma (SCC) with a PD-L1 TAP score ≥5% based on the RATIONALE-306 trial. Tislelizumab and nivolumab are recommended as second-line options for advanced esophageal SCC based on the ATTRACTION-3 and RATIONALE-302 trials. .

Background

Overview

Definition
Esophageal cancer refers to malignant disease arising from the esophageal epithelium, and principally comprises SCC and adenocarcinoma.
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Pathophysiology
Exposure to various carcinogens, genetic susceptibility, and repeated insults to the esophageal mucosa increase the risk of malignant transformation of esophageal epithelial cells, with the subsequent development of esophageal cancer.
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Epidemiology
The overall annual incidence of esophageal cancer in the US is 4.7 cases per 100,000 person-years.
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Disease course
Predominant changes in the squamous mucosa of the proximal esophagus predispose to esophageal SCC, while intestinal metaplasia of the mucosa of the distal esophagus predisposes to esophageal adenocarcinoma.
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Prognosis and risk of recurrence
The overall 5-year survival rate of patients with esophageal cancer is estimated at 15-20%.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of esophageal cancer are prepared by our editorial team based on guidelines from the European Society of Medical Oncology (ESMO 2025,2022), the European Hip Society (EHS/EAU/ISTH/EACTAIC/EACTS/AATS/ESTS/EBCOG/EKS/ESAIC/NATA/SRLF/EURAPS 2024), the Society of Thoracic Surgeons (STS/ASTRO 2024), the American Society of Clinical Oncology (ASCO 2023,2021,2020), the Japan Endocrine Society (JES 2023), the Society for ...
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Screening and diagnosis

Indications for screening, GERD: as per CTFPHC 2020 guidelines, do not screen adult patients with chronic GERD for esophageal adenocarcinoma or precursor conditions (Barrett's esophagus or dysplasia).
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  • Indications for screening (Barrett's esophagus, general principles)

  • Indications for screening (Barrett's esophagus, without dysplasia)

  • Indications for screening (Barrett's esophagus, with dysplasia)

  • Indications for screening (Barrett's esophagus, post-treatment)

Classification and risk stratification

Staging: as per ACR 2022 guidelines, obtain CT of the chest and abdomen with IV contrast or FDG-PET/CT of the skull base to mid-thigh for initial staging of patients with newly diagnosed esophageal cancer.
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Diagnostic procedures

Upper gastrointestinal endoscopy: as per ESMO 2022 guidelines, perform upper gastrointestinal endoscopy in patients with new dysphagia, gastrointestinal bleeding, recurrent aspiration or emesis and weight loss and/or loss of appetite.
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  • Biopsy and histopathology

  • Ancillary testing (flow cytometry)

  • Ancillary testing (PD-L1 testing)

  • Ancillary testing (HER2 testing)

  • Ancillary testing (MMR/MSI)

  • Ancillary testing (tumor mutational burden)

  • Ancillary testing (genomic testing)

  • Ancillary testing (EBV testing)

Medical management

General principles
As per ESMO 2025 guidelines:
Obtain multidisciplinary assessment and planning before commencing any treatment.
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Consider offering multimodality treatment in all patients with locally advanced resectable esophageal cancer.
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  • Management of locally advanced disease (chemoradiotherapy)

  • Management of locally advanced disease (surgery)

  • Management of locally advanced disease (immunotherapy)

  • Management of advanced/metastatic disease (systemic therapy)

  • Management of advanced/metastatic disease (chemoradiotherapy)

  • Management of advanced/metastatic disease (surgery)

  • Palliative care

Nonpharmacologic interventions

Nutritional support: as per ESMO 2022 guidelines, assess nutritional status and history of weight loss
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and provide nutritional support as appropriate.
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Perioperative care

Analgesia: as per AUGIS/POQI 2022 guidelines, perform either thoracic epidural or paravertebral blockade as the primary method of analgesia for esophagectomy to reduce pulmonary complications.
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  • Perioperative thromboprophylaxis

  • Perioperative supportive care

  • Perioperative nutrition

  • Postoperative rehabilitation

Surgical interventions

Technical considerations for surgery: as per ESMO 2022 guidelines, perform laparoscopy in patients with locally advanced (T3/T4) adenocarcinoma of the GEJ crossing the diaphragm to infiltrate the anatomical cardia.
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Patient education

General counseling: as per ASGE 2013 guidelines, consider a variety of factors, including patient preferences, QoL, and prognosis with the patient and family before initiating endoscopic palliation for esophageal malignancy.
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Follow-up and surveillance

Follow-up: as per ACR 2022 guidelines, obtain FDG-PET/CT of the skull base to mid-thigh for the evaluation of patients with esophageal cancer undergoing treatment.
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