Upper GI: Oesophageal neoadjuvant chemoradiotherapy (CROSS)
Free question published 26 July 2026
A 63-year-old man with a 4 cm adenocarcinoma of the distal oesophagus is staged cT3N1M0 on endoscopic ultrasound, CT and PET-CT. He has WHO performance status 0 and is fit for surgery, and the upper GI MDT recommends a trimodality approach with planned oesophagectomy. Which neoadjuvant regimen is the standard of care to offer before surgery?
- ACarboplatin (AUC 2) and paclitaxel (50 mg/m2) weekly with concurrent radiotherapy 41.4 Gy
- BDefinitive radiotherapy 66 Gy in 33 fractions alone
- CPerioperative epirubicin, cisplatin and 5-fluorouracil (ECF) without radiotherapy
- DCisplatin and 5-fluorouracil chemotherapy with concurrent radiotherapy to 50.4 Gy in 28 daily fractions
- ESingle-agent capecitabine with concurrent radiotherapy 45 Gy in 25 fractions
Why A is correct
The CROSS trial established neoadjuvant chemoradiotherapy with five weekly cycles of carboplatin (AUC 2) and paclitaxel (50 mg/m2) and concurrent radiotherapy of 41.4 Gy in 23 fractions, followed by surgery, as a standard of care for resectable oesophageal and junctional cancer. This regimen improved median overall survival to 49.4 versus 24.0 months with surgery alone (HR 0.66), and is endorsed by NICE NG83 for localised oesophageal/GOJ adenocarcinoma.
And why the others are not
- BDefinitive radiotherapy alone is not standard radical management and forgoes the survival benefit of trimodality therapy in a fit, operable patient.
- CPerioperative ECF (the MAGIC regimen) is a chemotherapy-only option; CROSS specifically combines carboplatin-paclitaxel with concurrent radiotherapy and is preferred for the trimodality approach asked about here.
- DCisplatin and 5-fluorouracil with 50.4 Gy is a definitive chemoradiotherapy backbone, not the CROSS neoadjuvant schedule, and the dose is higher than the 41.4 Gy used preoperatively.
- ESingle-agent capecitabine with 45 Gy is not the CROSS regimen and was not the schedule that demonstrated the survival benefit.
Source CROSS - Neoadjuvant chemoradiotherapy plus surgery versus surgery alone for oesophageal or junctional cancer — Shapiro J, van Lanschot JJB, Hulshof MCCM, et al. Neoadjuvant chemoradiotherapy plus surgery versus surgery alone for oesophageal or junctional cancer (CROSS): long-term results of a randomised controlled trial. Lancet Oncol. 2015;16(9):1090-1098. (Original report: van Hagen P, et al. N Engl J Med. 2012;366:2074-2084.)
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