What is the best neoadjuvant regimen prior to oesophagectomy: chemotherapy or chemoradiotherapy?

A best evidence topic in upper gastrointestinal surgery was written according to a structured protocol. The question addressed was whether neoadjuvant chemotherapy (CT) or chemoradiotherapy (CRT) in patients with resectable oesophageal cancer is associated with the best clinical outcome. 1115 papers were found of which 5 papers were identified to answer the clinical question including 2 randomised controlled trials (level II), 2 prospective series (level II) and one retrospective study (level III). The evidence suggests CRT significantly increases the pathological complete response rate and in some studies this is associated with a significant survival advantage. This is at the cost of an increase in peri-operative morbidity and mortality. However, both randomised studies were significantly underpowered and no standard CT or CRT regimen appears to have been used in any study. Therefore, controversy still exists as to whether neoadjuvant CT or CRT is more beneficial and this has lead to variation in practice around the globe. Two randomised controlled trials are currently underway which will hopefully answer this important clinical question.