ISDE guidelines on the management of cT2N0 esophageal cancer

Esophageal cancer incidence is rising globally, with at least 500,000 new cases diagnosed annually. Management options for non-metastatic disease include primary resection, neoadjuvant or perioperative therapies, or definitive non-surgical treatment, with the choice being guided by tumor staging, histology, patient fitness, and available resources. However, even with the use of advanced diagnostic modalities, preoperative clinical staging is challenging with respect to accuracy of both tumor and nodal assessment. Early-stage esophageal cancer may be managed with local therapies, such as endoscopic mucosal resection or submucosal dissection, while for more advanced tumors managed with curative intent neoadjuvant oncologic therapy is commonly recommended. However, between these two groups lies an infrequent but important subgroup of patients, clinically staged cT2N0M0 esophageal cancer. Guidelines such as the NIH's National Cancer Institute recommends either surgery alone or neoadjuvant therapy followed by surgery for AJCC Stage I cancers, and add the option of definitive chemoradiation for Stage II disease. With cT2N0 disease straddling both AJCC classifications, management guidance is lacking. This guideline will provide an evidence-based recommendation from the International Society For Disease Of The Esophagus on the management of cT2N0 esophageal cancer, of all types. The recommendations are intended to support surgeons, oncologists, and patients in decisions about the best practice preoperative oncologic management of cT2N0M0 esophageal cancer. A Working Group within the International Society for Diseases of the Esophagus (ISDE) Guidelines Committee performed a systematic review of the literature. Results of the systematic review were presented to a panel of experts and these results informed the panel discussion about the guideline. This panel used Grading of Recommendations Assessment, Development, and Evaluation approach to deliberate and formulate recommendations. The panel agreed on a conditional recommendation for the use of neoadjuvant therapy followed by surgery over primary surgical resection (PSR) for adult patients with cT2N0M0 esophageal cancer. Preoperative clinical staging of esophageal cancer is uncertain, with deficiencies in all diagnostic modalities. However, when all modern staging techniques are utilized, the ISDE recommends neoadjuvant therapy followed by surgical resection as the favored treatment of cT2N0 esophageal cancer. Certain patient groups may still be offered PSR, particularly those unable to tolerate neoadjuvant therapies, or those patients with very low risk of lymph node metastasis as suggested by histological features, small tumor size, and other features.