Elsevier

The Annals of Thoracic Surgery

Volume 98, Issue 5, November 2014, Pages 1880-1885
The Annals of Thoracic Surgery

Special report
The Society of Thoracic Surgeons Practice Guidelines on the Role of Multimodality Treatment for Cancer of the Esophagus and Gastroesophageal Junction

https://doi.org/10.1016/j.athoracsur.2014.07.069Get rights and content

Section snippets

Executive Summary

  • 1.

    Class I Recommendation: Patients with potentially curable, locally advanced esophageal cancer should be cared for in a multidisciplinary setting. (Level of Evidence B)

  • 2.

    Class I Recommendation: Restaging studies after neoadjuvant therapy are recommended before resection to rule out interval development of distant metastatic disease. (Level of Evidence B)

  • 3.

    Class IIA Recommendation: Endoscopic ultrasound restaging for residual local (mural) disease is inaccurate and can be omitted. (Level of Evidence

Methods

Our Task Force was tasked with addressing the factors affecting the treatment of locoregional esophageal cancers. This clearly includes patients with stage III disease because they have involved regional lymph nodes. It may also be reasonable to consider multimodality therapy for clinical stage II patients that are at high risk for systemic disease such as cT3 N0 patients 1, 2. For this systematic review of multimodality therapy, specific search terms were identified, and targeted searches were

Multimodality Care

  • 1.

    Class I Recommendation: Patients with potentially curable, locally advanced esophageal cancer should be cared for in a multidisciplinary setting. (Level of Evidence B)

Advances in surgical techniques, postoperative management, and staging modalities, combined with multidisciplinary team approaches, have resulted in a dramatic improvement in outcome results in the surgical treatment of cancer of the esophagus and gastroesophageal junction during the last 3 decades, with 5-year survival now in the

Restaging

  • 2.

    Class I Recommendation: Restaging studies after neoadjuvant therapy are recommended before resection to rule out interval development of distant metastatic disease. (Level of Evidence B)

  • 3.

    Class IIA Recommendation: Endoscopic ultrasound restaging for residual local (mural) disease is inaccurate and can be omitted. (Level of Evidence B)

  • 4.

    Class IIA Recommendation: A positron emission tomography scan is recommended for restaging after neoadjuvant therapy to detect interval development of distant

Neoadjuvant RT

  • 5.

    Class III Recommendation: Radiotherapy as monotherapy before resection is not recommended. (Level of Evidence A)

None of the five randomized trials comparing preoperative RT plus operation with operation alone or meta-analyses have found an improvement in resectability or outcome for esophageal cancer 13, 14, 15. As a consequence, preoperative RT alone is not considered to be efficacious as the neoadjuvant component of a multimodality program for esophageal cancer.

Neoadjuvant CT

  • 6.

    Class IIA Recommendation: Neoadjuvant platinum-based doublet chemotherapy alone is beneficial before resection for patients with locally advanced esophageal adenocarcinoma. (Level of Evidence A)

Ten randomized trials comparing CT plus operation vs a primary operation have been reported. The two largest of these reported conflicting results. The United States trial did not show any difference in the variables that were analyzed [16]. In contrast, the United Kingdom–based trial did find a small

Value of Surgical Resection After Neoadjuvant Therapy

  • 8.

    Class I Recommendation: After neoadjuvant therapy, patients without metastatic disease, in whom surgical resection can be safely performed, should receive esophageal resection. (Level of Evidence A)

Surgical resection after neoadjuvant therapy in patients with a CR or PR should take place as long as all known disease, primary tumor, and regional lymph nodes are completely resectable (ie, a R0 resection is expected). Of course, this excludes patients with new metastases or local disease

Adjuvant Therapy

  • 9.

    Class IIA Recommendation: Patients with adenocarcinoma who have not received neoadjuvant therapy should be considered for adjuvant chemoradiotherapy if the pathologic specimen reveals regional lymph node disease. (Level of Evidence B)

Conflicting results obtained from different trials of induction therapy and the difficulties in distinguishing the patients who will benefit (responders) from those who will not (nonresponders) have suggested assessing the value of adjuvant therapy.

Postoperative

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    Report from The Society of Thoracic Surgeons Workforces on Evidence Based Surgery and General Thoracic Surgery.

    The Society of Thoracic Surgeons Clinical Practice Guidelines are intended to assist physicians and other health care providers in clinical decision making by describing a range of generally acceptable approaches for the diagnosis, management, or prevention of specific diseases or conditions. These guidelines should not be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the same results. Moreover, these guidelines are subject to change over time, without notice. The ultimate judgment regarding the care of a particular patient must be made by the physician in light of the individual circumstances presented by the patient.

    For the full text of this and other STS Practice Guidelines, visit http://www.sts.org/resources-publications on the official STS Web site (www.sts.org).

    View full text