Multimodality Therapy for Locally-Advanced Cancer of the Esophagus or Gastroesophageal Junction

Publication Date: November 2, 2023
Last Updated: November 14, 2023

Induction Chemotherapy

Induction chemotherapy before preoperative CRT with a positron emission tomography (PET)-based response assessment and adaptation of the regimen accordingly during CRT may be reasonable in patients with resectable esophageal adenocarcinoma (AC). (IIb, B-NR)

Administration of induction chemotherapy before neoadjuvant CRT (nCRT) without early response assessment and response-adapted therapy during radiotherapy is not recommended. (III - No Benefit, B-R)

Neoadjuvant Chemotherapy vs Neoadjuvant CRT

In patients with locally-advanced SCC of the esophagus, nCRT is reasonable to choose over neoadjuvant chemotherapy (nCT). (IIa, B-R)

In patients with locally advanced AC of the esophagus or gastroesophageal junction, either nCRT or nCRT are reasonable to choose. (IIa, B-R)

Optimal Dose for Radiotherapy

When radiotherapy is planned as part of preoperative CRT, a dose of 41.4 Gy to 50.4 Gy is reasonable. (IIa, B-NR)

A dose of 50 to 50.4 Gy in 25 to 28 fractions is recommended for patients treated with dCRT. (I, A)

Value of Surgery

Surgery after CRT is recommended as the standard of care in patients with AC. (I, C-LD)

Surgery is recommended in medically operable patients with SCC when a clinical complete response (cCR) is not achieved after CRT. (I, B-NR)

Either surgery or observation is reasonable in low operative–risk patients with SCC who achieve a cCR after CRT. (IIa, B-NR)

Timing of Esophagectomy After Neoadjuvant CRT

In patients who have recovered sufficiently and are ready for surgery, timing of surgery before 7 to 8 weeks after nCRT may result in a slight OS advantage, with a lower risk of perioperative morbidity and mortality and is reasonable when possible. (IIa, B-NR)

For patients undergoing surgery after nCRT, surgery should not be scheduled before 4 weeks after completion of nCRT. (III - Harm, C-LD)

Transhiatal Esophagectomy vs Transthoracic Esophagectomy

In the setting of nCRT, both transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) are reasonable approaches. (IIa, B-NR)

Minimally Invasive Esophagectomy

Minimally invasive esophagectomy (MIE) has the potential to reduce perioperative pulmonary complications and improve short-term quality of life and is reasonable to consider. (IIa, B-R)

Adjuvant Systemic Therapy

Adjuvant nivolumab is recommended in patients with residual disease after nCRT and no contraindications. (I, B-R)

Recommendation Grading


  • AC: Esophageal Adenocarcinoma
  • CCR: Clinical Complete Response
  • MIE: Minimally Invasive Esophagectomy
  • PET: Positron Emission Tomography
  • THE: Transhiatal Esophagectomy
  • TTE: Transthoracic Esophagectomy
  • nCT: Neoadjuvant Chemotherapy


The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.



Multimodality Therapy for Locally-Advanced Cancer of the Esophagus or Gastroesophageal Junction

Authoring Organizations

Publication Month/Year

November 2, 2023

Last Updated Month/Year

December 19, 2023

Document Type


Country of Publication


Document Objectives

Outcomes for patients with esophageal cancer have improved over the last decade with the implementation of multimodality therapy. There are currently no comprehensive guidelines addressing multidisciplinary management of esophageal cancer that have incorporated the input of surgeons, radiation oncologists, and medical oncologists. To address the need for multidisciplinary input in the management of esophageal cancer and to meet current best practices for clinical practice guidelines, the current guidelines were created as a collaboration between The Society of Thoracic Surgeons (STS), American Society for Radiation Oncology (ASTRO), and the American Society of Clinical Oncology (ASCO). Physician representatives chose 8 key clinical questions pertinent to the care of patients with locally advanced, resectable thoracic esophageal cancer (excluding cervical location). A comprehensive literature review was performed identifying 227 articles that met the inclusion criteria covering the use of induction chemotherapy, chemotherapy vs chemoradiotherapy before surgery, optimal radiation dose, the value of esophagectomy, timing of esophagectomy, the approach and extent of lymphadenectomy, the use of minimally invasive esophagectomy, and the value of adjuvant therapy after resection. The relevant data were reviewed and voted on by the panel with 80% of the authors, with 75% agreement on class and level of evidence. These data were then complied into the guidelines document.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Treatment, Management

Diseases/Conditions (MeSH)

D005770 - Gastrointestinal Neoplasms, D046152 - Gastrointestinal Stromal Tumors, D016629 - Esophagectomy


Esophageal cancer, Gastroesophageal cancer, gastroesophageal adenocarcinoma, esophagectomy

Source Citation

Worrell SG, Goodman KA, Altorki NK, Ashman JB, Crabtree TD, Dorth J, Firestone S, Harpole DH, Hofstetter WL, Hong TS, Kissoon K, Ku GY, Molena D, Tepper JE, Watson TJ, Williams T, Willett C. The Society of Thoracic Surgeons/American Society for Radiation Oncology Updated Clinical Practice Guidelines on Multimodality Therapy for Locally Advanced Cancer of the Esophagus or Gastroesophageal Junction. Ann Thorac Surg. 2023 Oct 27:S0003-4975(23)00973-6. doi: 10.1016/j.athoracsur.2023.09.021. Epub ahead of print. PMID: 37921794.


Number of Source Documents
Literature Search Start Date
March 1, 2021
Literature Search End Date
June 1, 2022