[Personalized systemic treatment of metastatic esophageal cancer]

The systemic treatment landscape of metastatic esophageal cancer has changed over the past decade. For a long time, platinum-based chemotherapy combinations were the only standard option but now immune checkpoint inhibitors, administered either as monotherapy or in combination with chemotherapy, enable a significantly improved overall survival in selected patients. Prerequisites for appropriate treatment selection are precise histological and molecular classifications of the tumor. In esophageal squamous cell carcinoma, histology and programmed cell death ligand 1 (PD-L1) expression are the principal determinants of first-line treatment. The use of different PD-L1 scoring systems in pivotal clinical trials complicates the application in routine practice. For esophageal adenocarcinoma palliative systemic treatment largely follows contemporary treatment algorithms for metastatic gastric and gastroesophageal junction cancer, incorporating the HER2, Claudin18.2, MSI/MMR and PD-L1 status. This review summarizes the current evidence, focusing on metastatic esophageal squamous cell carcinoma and provides practical recommendations for multidisciplinary patient management.