ESMO Clinical Practice Guideline interim update on the treatment of locally advanced oesophageal and oesophagogastric junction adenocarcinoma and metastatic squamous-cell carcinoma
- Study type
- Clinical guideline
- Study name
- ESMO 2025 (eUpdate)
- Design
- Interim update (eUpdate) of the 2022 ESMO clinical guideline on oesophageal cancer
- Source
- ESMO Open · 2025
In plain words
In 2025 the European Society for Medical Oncology (ESMO) updated its guideline for treating oesophageal cancer. The most important change is that in the "adenocarcinoma" type that can be operated on, the four-drug chemotherapy FLOT given before and after surgery is the preferred approach, and chemoradiotherapy before surgery is for patients who cannot tolerate FLOT. For the advanced "squamous" type, new immunotherapy drugs were added to the options. All patients with locally advanced oesophageal cancer should consider combined treatment (more than one method).
Key guideline recommendations
- I, A
Multimodal (combined) treatment should be considered for all patients with locally advanced, resectable oesophageal cancer.
- I, A
Patients with locally advanced, resectable adenocarcinoma of the oesophagus or oesophagogastric junction should be treated with perioperative FLOT and surgery (ESMO-MCBS v1.1 score: A).
- I, C
If the patient is not suitable for FLOT, neoadjuvant chemoradiotherapy may be considered.
- I, A
Tislelizumab plus chemotherapy is recommended for first-line treatment of advanced oesophageal squamous-cell carcinoma in patients with a PD-L1 TAP score ≥5% (ESMO-MCBS v1.1: 4; EMA-approved, not FDA-approved).
- I, A
Tislelizumab (ESMO-MCBS: 4) or nivolumab (ESMO-MCBS: 3) is recommended for oesophageal squamous-cell carcinoma previously treated with platinum–fluoropyrimidine chemotherapy.
Study population
Patients with locally advanced, resectable adenocarcinoma of the oesophagus or oesophagogastric junction, and patients with advanced or metastatic squamous-cell carcinoma of the oesophagus.
Clinical significance and place in guidelines
Based on the ESOPEC trial, this update made perioperative FLOT the preferred standard in locally advanced oesophageal and OGJ adenocarcinoma, and it also cites the Neo-AEGIS and TOPGEAR evidence. For advanced squamous-cell carcinoma, tislelizumab plus chemotherapy (RATIONALE-306 trial) was added for PD-L1 TAP ≥5% (EMA-approved, not FDA-approved). For locally advanced squamous-cell carcinoma, the recommendations of the original 2022 guideline (Obermannová et al., Ann Oncol 2022) stand. Note: in 2026 ESMO published a combined guideline for "gastric and oesophageal cancer" (Al-Batran et al., Ann Oncol 2026; DOI: 10.1016/j.annonc.2026.09.015), which physicians should consult for the latest recommendations.
Limitations
This document only updates specific sections of the 2022 guideline and does not cover all aspects of diagnosis, staging and treatment. Toripalimab (JUPITER-06 trial) was not recommended because of the lack of data outside the Chinese population.
This summary was prepared by the editorial team from the published paper; the original paper is the final reference. Read the original abstract on PubMed.