5 things that surgeons should know about neoadjuvant treatment in esophageal cancer

Esophageal cancer is the 8thmost common malignant disease, with more than 380,000 deaths every year. Adenocarcinoma and squamous cell carcinoma represent more than 98% of esophageal tumors. It is well known that the locally advanced disease (cT3-T4 or cN1-3 M0) has an increased risk of R1 resection and micrometastatic nodules, and therefore current guidelines recommend perioperative treatment besides surgery.

Perioperative treatment is currently based on perioperative chemotherapy or neoadjuvant chemoradiotherapy. These therapies seek to downstage the tumor, as this increases the possibility of R0 resection and improves recurrence and survival outcomes. Moreover, chemotherapy targets micrometastatic disease, thus limiting the risk of distant spread. On the other hand, the postoperative complications and toxicity associated with these oncological treatments must also be considered.

Squamous cell carcinoma can be treated by neoadjuvant chemoradiotherapy and esophagectomy. However, several oncology and surgical units are using definitive chemoradiotherapy without surgery as a curative treatment, and they reserve salvage surgery for persistent recurrent disease. In esophageal adenocarcinoma, high-quality trials have reported good outcomes with perioperative chemotherapy and neoadjuvant chemoradiotherapy.

In this talk, we will focus on the details of neoadjuvant treatment in esophageal cancer: why, when, and how to use it? We will go into the details of big trials such as the FLOT and CROSS studies. Finally, we will discuss the new drugs and the importance of targeted therapies.