Upper GI: Oesophageal neoadjuvant chemoradiotherapy (CROSS)

Why A is correct

CROSS established neoadjuvant carboplatin (AUC 2) and paclitaxel (50 mg/m2) weekly with concurrent radiotherapy of 41.4 Gy in 23 fractions, followed by surgery, as a standard of care for resectable oesophageal and junctional cancer; median overall survival was 49.4 versus 24.0 months with surgery alone (hazard ratio 0.66), with a particularly marked effect in squamous cell carcinoma. NICE NG83 offers people with resectable non-metastatic squamous cell carcinoma of the oesophagus the choice of radical chemoradiotherapy or chemoradiotherapy before surgical resection; having opted for the trimodality approach, the CROSS regimen is the appropriate neoadjuvant schedule before oesophagectomy in this patient.

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 that NICE NG83 offers for localised oesophageal or junctional adenocarcinoma (1.4.5), not the guideline's pathway for squamous cell carcinoma; it also lacks the concurrent radiotherapy of 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.)