Esophageal Cancer Practice Guidelines in Japan

The Esophageal Cancer Practice Guidelines 2022 by the Japan Esophageal Society (JES) represent a methodologically renewed, stage-stratified update created through predefined Clinical Questions, systematic reviews, consensus voting, and external/public review. This chapter synthesizes the 2022 recommendations and incorporates post-publication rapid updates through November 2025. Key advances include: (1) clearer stage-based algorithms (cStage 0–I, II–III, IVA, IVB) with multidisciplinary selection; (2) formal integration of esophagogastric junction (EGJ) carcinoma in collaboration with the Japanese Gastric Cancer Association, using esophageal invasion length to guide approach and lymphadenectomy; and (3) strengthened guidance on surveillance, palliation, and Barrett’s/esophageal adenocarcinoma. For resectable cStage II–III, preoperative triplet chemotherapy with docetaxel, cisplatin, and fluorouracil replaces cisplatin plus fluorouracil as the new standard (JCOG1109); adjuvant nivolumab is recommended only after neoadjuvant chemoradiotherapy (CRT) with residual disease. The surgical section now has level-1 support for minimally invasive surgery: JCOG1409 demonstrated non-inferior overall survival for thoracoscopic versus open transthoracic esophagectomy, after which the JES (Nov 2025, CQ22) issued a strong recommendation for thoracoscopic esophagectomy when performed by Japan Society of Endoscopic Surgery (JSES)-certified or equivalently skilled surgeons (or under direct supervision). For cStage IVB/recurrent disease, immunochemotherapy is embedded as first-line care; the April 2025 JES rapid update adds tislelizumab plus cisplatin and fluorouracil as a strongly recommended first-line option (PD-L1 considered) and tislelizumab monotherapy as a strongly recommended second-line option in PD-1-naïve patients after fluoropyrimidine–platinum therapy. The guideline further details definitive CRT, evolving roles of salvage and conversion surgery (with results of JCOG1510 awaited), and pragmatic palliative pathways, emphasizing nutrition, airway safety, and early palliative-care integration. Overall, the 2022 framework—now augmented by 2025 evidence—provides a contemporary, evidence-anchored roadmap tailored to Japanese practice while remaining interpretable internationally.