International survey on esophageal cancer: part II staging and neoadjuvant therapy

Abstract

The outcome of esophagectomy could be improved by optimal diagnostic strategies leading to adequate preoperative patient selection. Neoadjuvant therapy could improve outcome by increasing the number of radical resections and by controlling metastatic disease. The purposes of this study were to gain insight into the current worldwide practice of staging modalities and neoadjuvant therapy in esophageal cancer, and to detect intercontinental differences. Surgeons with particular interest in esophageal surgery, including members of the International Society for Diseases of the Esophagus, the European Society of Esophagology - Group d'Etude Européen des Maladies de l'Oesophage, and the OESO, were invited to participate in an online questionnaire. Questions were asked regarding staging modalities, neoadjuvant therapy, and response evaluation applied in esophageal cancer patients. Of 567 invited surgeons, 269 participated resulting in a response rate of 47%. The responders currently performing esophagectomies (n= 250; 44%) represented 41 countries across the six continents. Esophagogastroscopy with biopsy and computed tomography (CT) scanning were routinely performed by 98% of responders for diagnosing and staging esophageal cancer, while endoscopic ultrasound (EUS) and barium esophagography were routinely applied by 58% and 51%, respectively. Neoadjuvant therapy is routinely administered by 33% and occasionally by 63% of responders. Of the responders that administer identical neoadjuvant regimens to esophageal adenocarcinoma (AC) and squamous cell carcinoma, 54% favor chemoradiotherapy. For AC, chemotherapy is preferred by 31% of the responders that administer neoadjuvant therapy, whereas for squamous cell carcinoma, the majority of responders (38%) prefer chemoradiotherapy. Response to neoadjuvant therapy is predominantly assessed by CT scanning of the chest and abdomen (86%). Barium esophagography, EUS, and combined CT/PET scan are requested for response monitoring in equal frequency (25%). Substantial differences in applied staging modalities and neoadjuvant regimens were detected between surgeons from different continents. In conclusion, currently the most commonly applied diagnostic modalities for staging and restaging esophageal cancer are CT scanning of the chest and abdomen, gastroscopy, barium esophagography and EUS. Neoadjuvant therapy is routinely applied by one third of the responders. Intercontinental differences have been detected in the diagnostic modalities applied in esophageal cancer staging and in the administration of neoadjuvant therapy. The results of this survey provide baseline data for future research and for the development of international guidelines.