American Radium Society (ARS) and American College of Radiology (ACR) Appropriate Use Criteria (AUC) Systematic Review and Guidelines for Operable Esophageal Adenocarcinoma

Document Type

Conference Proceeding

Publication Date


Publication Title

International Journal of Radiation Oncology, Biology & Physics


Background: The ARS AUC are evidence-based guidelines that are reviewed by a multidisciplinary expert panel.

Objectives: Our goal was to summarize the literature regarding outcomes following surgery alone as well as neoadjuvant, adjuvant, and definitive chemotherapy and/or radiation treatment strategies for the treatment of operable adenocarcinoma of the esophagus and gastroesophageal junction (GEJ).

Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematic review assessed all studies within Ovid Medline, Embase, and Cochrane Central Databases published through 6/2019 evaluating toxicities, local control and/or overall survival (OS) for operable esophageal adenocarcinoma. Of 2786 abstracts screened, 77 full text articles were assessed for eligibility after which 45 remained after exclusions and formed the basis for our findings.

Results: Several meta-analyses have concluded that neoadjuvant chemoradiation (nCRT) is associated with significant improvements in OS and R0 resection rate compared to surgery alone. Compared to neoadjuvant chemotherapy (nCT), nCRT significantly increased the incidence of locoregional control, pathologic complete response and R0 resection rate for esophageal/GEJ patients; however, this did not translate to an improvement in OS. In a meta-analysis of patients with esophageal cancer, the OS benefit found comparing nCT or peri-operative chemotherapy to surgery alone was lost on subset analysis for adenocarcinoma. Although several meta-analyses have not found an increase in complications with nCRT, one network meta-analysis found a strong trend towards increased post-operative mortality with nCRT compared to either surgery alone or nCT. In a meta-analysis of studies comparing definitive CRT (dCRT) vs. nCRT, OS was significantly lower for dCRT. However, when only analyzing studies with equal stage/performance status patients at baseline, no significant differences were found. However, small numbers of adenocarcinoma patients limits definitive conclusions. For T2N0 patients, compared to surgery alone the addition of neoadjuvant radiation with or without chemotherapy was found to improve R0 resection rate but not OS; however, studies have demonstrated that over one third of patients are clinically understaged. Adjuvant CRT following upfront surgery is controversial and interpretation is limited by small numbers of adenocarcinoma patients, and an OS benefit was only noted on subset analysis for those with positive lymph nodes.

Conclusions: Although a number of meta-analyses comparing various treatment options for operable esophageal cancer exist, limited numbers of adenocarcinoma patients often hinder definitive conclusions. Optimum oncologic outcomes are most consistently described with nCRT except for early stage T2N0 patients, and the potential for increased post-operative mortality with nCRT should be acknowledged. ARS AUC committee recommendations will be presented.





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