Multimodality treatment for localized gastro-oesophageal cancer

Surgery alone remains an international standard of care for early stage (Ia) oesophagogastric cancers. There is also international consensus that multimodality therapy is appropriate for more advanced stage operable disease, however there is marked geographical variation in standard practice. For gastric adenocarcinomas, adjuvant oral fluoropyrimidines became the standard of care in Japan after improved survival was demonstrated following resection with D2 nodal dissection, compared to surgery alone. Adjuvant chemoradiation improves survival following surgery with any level of nodal dissection compared to observation and is the accepted standard of care in the US. Similarly, perioperative triplet chemotherapy improves survival compared to surgery alone in gastroesophageal adenocarcinomas and is widely used across Europe and Australasia. For oesophageal adenocarcinoma, neo-adjuvant chemotherapy and neo-adjuvant chemoradiation are further accepted standards, widely utilized in the UK and US respectively, with similar survival benefits reported for each strategy. Patients with localized squamous cell carcinomas of the oesophagus benefit from chemoradiation, which may be delivered as a neo-adjuvant or definitive strategy, the latter avoiding surgical morbidity and mortality. Targeted agents are currently under evaluation in localized oesophagogastric cancer, with translational sub-studies attempting to define which patients may benefit from the addition of these high cost drugs.