Treatment of Cancer of the Esophagus
-
Upload
robert-j-miller-md -
Category
Health & Medicine
-
view
454 -
download
11
description
Transcript of Treatment of Cancer of the Esophagus
![Page 1: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/1.jpg)
Cancer of the EsophagusTreatment Optionswww.aboutcancer.com
![Page 2: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/2.jpg)
![Page 3: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/3.jpg)
NCCN.org
![Page 4: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/4.jpg)
![Page 5: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/5.jpg)
Staging System, T and N for Esophagus Cancer
Tis T1intramucosal
T1submucosal
aorta
T4T3T2
N0N11-2 nodes
Mucosa
N23-6 nodes
N37+nodes
Muscularispropria
Submucosa
![Page 6: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/6.jpg)
Tis
Endoscopic Resection or
Ablation
Esophagectomy
![Page 7: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/7.jpg)
EMR Endoscopic Mucosal Resection
![Page 8: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/8.jpg)
![Page 9: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/9.jpg)
EMR (endoscopic mucosal resection)
![Page 10: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/10.jpg)
EMR
![Page 11: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/11.jpg)
Photodynamic Therapy
![Page 12: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/12.jpg)
Endoscopic Resection
EMR (endoscopic mucosal resection) or ESD (endoscopic submucosal dissection) or ablation (e.g. RFA or radiofrequency ablation or cryoablation or photodynamic therapy)
Goal is the complete removal and eradication of all cancer in early stage disease (Tis or T1a)
![Page 13: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/13.jpg)
One of the largest studies with long-term follow-up included 402 patients with superficial esophageal squamous carcinoma
The patients were treated either with EMR (48 percent) or ESD (52 percent) The overall survival rates was 84 percent.
Survival was highest among patients whose tumors did not invade beyond the lamina propria (five-year survival rate of 91 percent).
The five-year survival rate was 71 percent both for patients with involvement of the muscularis mucosa and for patients with involvement of the submucosa.
Am J Gastroenterol. 2013;108(4):544.
![Page 14: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/14.jpg)
EMR or ESD• A meta-analysis of 15 studies found that ESD,
compared with EMR, had higher en bloc and curative resection rates as well as lower rates of local recurrence for malignant and premalignant lesions of the gastrointestinal tract. Similar results were noted in two other meta-analyses
• In a retrospective study of 300 patients with squamous cell cancer of the esophagus, patients who underwent resection with ESD had significantly higher en bloc resection rates and lower local recurrence rates compared with patients who underwent EMR (100 versus 53 percent and 1 versus 10 percent, respectively)
![Page 15: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/15.jpg)
T1a
Endoscopic Resection plus
Ablation
Esophagectomy
![Page 16: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/16.jpg)
T1bN0 Esophagectomy
For superficial T1b adenocarcinoma consider endoscopic resection
![Page 17: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/17.jpg)
French FFCD 9901 trial, which randomly assigned 195 patients with stage I or II esophageal or EGJ cancer to preoperative chemoradiotherapy (fluorouracil plus cisplatin and concurrent RT [45 Gy]) versus surgery alone
Results Chem/Rad/Sug Surgery Alone
Survival 32 mos 44 mosAdverse Events 65% 35%%Mortality 7.3% 1.1%
J Clin Oncol 2010; 28:302s
![Page 18: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/18.jpg)
T1bN+ or T2-T4a
Squamous
PreOp Chemoradiation
then Surgery
Esophagectomylow risk
Chemoradiation
![Page 19: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/19.jpg)
.A meta-analysis of randomized controlled trials that compared neoadjuvant chemoradiation and surgery to surgery alone for resectable esophageal cancer.Urschel JD, Vasan H Am J Surg.2003 Jun;185(6):538-43
Compared with surgery alone, neoadjuvant chemoradiation and surgery improved 3-year survival and reduced local-regional cancer recurrence.
![Page 20: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/20.jpg)
Preoperative chemoradiotherapy for oesophageal cancer: a systematic review and meta-analysis.Gut.2004 Jul;53(7):925-30.
In patients with resectable oesophageal cancer, chemoradiotherapy plus surgery significantly reduces three year mortality (OR = 0.53) compared with surgery alone. However, postoperative mortality was significantly increased (OR = 2.10) by neoadjuvant chemoradiotherapy.
![Page 21: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/21.jpg)
Survival after neoadjuvant chemotherapy or chemoradiotherapy for resectable oesophageal carcinoma: an updated meta-analysis.Lancet Oncol.2011 Jul;12(7):681-92.
The HR for all-cause mortality for neoadjuvant chemoradiotherapy was 0.78. The HR for the overall indirect comparison of all-cause mortality for neoadjuvant chemoradiotherapy versus neoadjuvant chemotherapy was 0.88.
This updated meta-analysis provides strong evidence for a survival benefit of neoadjuvant chemoradiotherapy or chemotherapy over surgery alone in patients with oesophageal carcinoma
![Page 22: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/22.jpg)
157 esophageal cancer patients at the University of Texas M.D. Anderson Cancer Center The treatment approaches included preoperative chemotherapy, n = 76 or preoperative C/RT, n = 81
Preoperative C/RT demonstrated increased pathologic complete response (28% versus 4%) and overall survival (3 years, 48% versus 29%)
Ann Thorac Surg. 2010 Sep;90(3):892-8;
![Page 23: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/23.jpg)
Preoperative Chemoradiotherapy for Esophageal or Junctional CancerP. van Hagen for the CROSS GroupN Engl J Med 2012; 366:2074-2084
randomly assigned patients with resectable tumors to receive surgery alone or weekly administration of carboplatin and paclitaxel for 5 weeks and concurrent radiotherapy (41.4 Gy), followed by surgery.
Results Chem/Rad/Surg Surgery Alone
R0 Resection92% 69%Path CR 19%Hospital Mortality 4% 4%Median Survival 49.4 mos 24.0 mosSurvival/5y 47% 34%
![Page 24: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/24.jpg)
Months
CRT + Surgery
Surgery
Survival
![Page 25: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/25.jpg)
Surgery Alone Versus Chemoradiotherapy Followed by Surgery for Stage I and II Esophageal Cancer: Final Analysis of Randomized Controlled Phase III Trial FFCD 9901
Christophe Mariette. J Clin Onc 2014: 2416
randomly assigned to surgery alone or NCRT followed by surgery. CRT protocol was 45 Gy with concomitant chemotherapy composed of fluorouracil and cisplatin
Results Chemo/Rad/Sug Surgery Alone
Survival/3 y 47.5% 53.0%PostOp Mortality 11.1% 3.4%
![Page 26: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/26.jpg)
Arm A chemotherapy and surgery median survival time 21.1 months, 3-year survival rate 27.7%.
Arm B chemoradiotherapy and surgery): median survival time 33.1 months, 3-year survival rate 47.7%.
JCO February 20, 2009vol. 27 no. 6 851-856
Comparison of Preoperative Chemotherapy Compared With Chemoradiotherapy
![Page 27: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/27.jpg)
Trial of Preoperative Oxaliplatin, Docetaxel, and Capecitabine With Concurrent Radiation Therapy (45Gy) in Localized Carcinoma of the Esophagus
pCR rate, 49%; Sixty-nine percent of patients underwent surgery. median disease-free survival (DFS) and overall survival (OS) were 16.3 and 24.1 months, respectively. Two-year DFS and OS were 45.1% and 52.2%, respectively.
Months
Over all Survival
Spigel J Clin Onc 2010:28:2213
![Page 28: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/28.jpg)
T1bN+ or T2-T4a
Squamous
PreOp Chemoradiation
then Surgery
Esophagectomylow risk
Chemoradiation
![Page 29: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/29.jpg)
Chemoradiotherapy of locally advanced esophageal cancer: long-term follow-up of a prospective randomized trial (RTOG 85-01). JAMA.1999 May 5;281(17):1623
Squamous cell or adenocarcinoma of the esophagus, T1-3 N0-1 M0. Combined modality therapy: 50 Gy plus cisplatin and fluorouracil, compared with RT only : 64 Gy in 32 fractions over 6.4 weeks.
Results Chemo-Radiation Radiation
Survival/5Y 14 – 26% 0%
![Page 30: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/30.jpg)
RTOG 94-05J Clin Onc 2002;20:1167
5-FU + cisplatin + radiation (64.8Gy or 50. 4Gy)
Results High Dose Low Dose
Median survival 13.0 mos 18.1 mosSurv/2y 31% 40%Local Failure 56% 52%
![Page 31: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/31.jpg)
Survival from 94-05
50.4Gy
64.8Gy
Months
![Page 32: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/32.jpg)
Randomized Trial of Two Nonoperative Regimens of Induction Chemotherapy Followed by Chemoradiation in Patients With Localized Carcinoma of the Esophagus: RTOG 0113
assigned to receive either induction with fluorouracil, cisplatin, and paclitaxel and then fluorouracil plus paclitaxel with 50.4 Gy of radiation (arm A) or induction with paclitaxel plus cisplatin and then the same chemotherapy with 50.4 Gy of radiation (arm B)
The median survival time was 28.7 months for patients in arm A and 14.9 months for patients in arm B (18.8 months for patients in RTOG 9405). The 2-year survival rate was 56% for arm A and 37% for arm B.
![Page 33: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/33.jpg)
ChemoRadiation Alone, RTOG
Months
Survival
RTOG 0113
RTOG 9405
JCO 2008;28:4551
![Page 34: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/34.jpg)
Survival with ChemoRadiation versus Esophagectomy
Chan. IJROBP ;1999:45:265
![Page 35: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/35.jpg)
10y Survival Chemoradiation with or without Surgery
2 4 6 8 10Years
No Surgery
Surgery
Bidoli. Cancer 2002:94:352
![Page 36: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/36.jpg)
Chemoradiation with and without surgery in patients with locally advanced squamous cell carcinoma of the esophagus.Stahl. J Clin Oncol. 2005 Apr 1;23(10):2310-7
locally advanced squamous cell carcinoma (SCC) of the esophagus were randomly allocated to either
Induction chemotherapy followed by chemoradiotherapy (40 Gy) followed by surgery (arm A),
or the same induction chemotherapy followed by chemoradiotherapy (at least 65 Gy) without surgery (arm B).
![Page 37: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/37.jpg)
Chemoradiation with and without surgery in patients with locally advanced squamous cell carcinoma of the esophagus.Stahl. J Clin Oncol. 2005 Apr 1;23(10):2310-7
overall survival to be equivalent between the two treatment groups
Local progression-free survival was better in the surgery group (2-year progression-free survival, 64.3%) than in the chemoradiotherapy group (2-year progression-free survival 40.7%
Treatment-related mortality was significantly increased in the surgery group than in the chemoradiotherapy group (12.8% v 3.5%)
![Page 38: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/38.jpg)
Years
Survival
Surgery
Radiation
J Clin Oncol. 2005 Apr 1;23(10):2310-7
![Page 39: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/39.jpg)
Chemoradiation followed by surgery compared with chemoradiation alone in squamous cancer of the esophagus: FFCD 9102.Bedenne.
J Clin Oncol. 2007 Apr 1;25(10):1160-8.
Patients received fluorouracil (FU) and cisplatin and either conventional (46 Gy) or split-course (15 Gy X 2) concomitant radiotherapy. Then randomly assigned to surgery (arm A) or continuation of chemoradiation (arm B;FU/cisplatin and either conventional [20 Gy] or split-course [15 Gy] radiotherapy).
Results Surgery Radiation
Survival/2y 34% 40% Median Surv 17.7 mos 19.3 mos Local Control 66% 57% Stent 5% 32%
![Page 40: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/40.jpg)
Chemoradiation followed by surgery compared with chemoradiation alone in squamous cancer of the esophagus: FFCD 9102.Bedenne.
J Clin Oncol. 2007 Apr 1;25(10):1160-8.
![Page 41: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/41.jpg)
No evidence
of Disease
Surveillance
Esophagectomy
What to Do after PreOp Chemoradiation?
![Page 42: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/42.jpg)
Persistent Disease
Esophagectomy
Palliative Care
What to Do after PreOp Chemoradiation?
![Page 43: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/43.jpg)
PostOperative Therapy
Types of Resection Based on Pathology Findings
R0 = No cancer at Resection MarginsR1 = Microscopic Residual at MarginsR2 = Macroscopic (obvious) residual or Metastases
![Page 44: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/44.jpg)
PostOperative Therapy
Squamous
R0 = SurveillanceR1 = Observation or ChemoradiationR2 = Chemoradiation or Palliation
![Page 45: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/45.jpg)
PostOperative Therapy
Adenocarcinoma
R0 = Surveillance for T1N0consider chemoradiation for others and for all N+R1 = ChemoradiationR2 = Chemoradiation or Palliation
![Page 46: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/46.jpg)
Surgery
![Page 47: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/47.jpg)
Surgery
remove replaced
![Page 48: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/48.jpg)
![Page 49: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/49.jpg)
Esophagus EsophagusEsophagus joined to stomachCancer
Cancer removed
Stomach Stomach
Surgery
![Page 50: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/50.jpg)
Principles of Surgery
All patients who are fit enough to undergo major resection (esophagectomy) should be considered for surgery unless:
Tumor is < 5cm from the cricopharyngeus (too high in the neck)
Superficial (Tis or Ta) enough that endoscopic surgery would be an option
Too locally advanced (inoperable or bulky lymph nodes or metastatic)
![Page 51: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/51.jpg)
T4b
Chemoradiation
Palliative Care
Chemo alone or Radiation alone
![Page 52: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/52.jpg)
Single Agent Chemotherapy
Drug Response Rate
5-FU 17%Doxorubicin 0%Cisplatin 19%Methotrexate 13%Paclitaxel 15-32%Docetaxel 20%Irinotecan 14%
![Page 53: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/53.jpg)
Chemotherapy
Cisplatin-fluorouracil , response rates of 20 – 30% , median survival of 8 months, and 30%/1 year survival
ECF (epirubicin, cisplatin, fluorouracil) ECX (capecitiabine) EOF (oxaliplatin) or EOX response rate was 40 to 48%, survival was 17 to 19 months, and 1 year survival 37 to 47%
N Engl J Med 2008; 358:36-46
![Page 54: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/54.jpg)
Chemotherapy
PreOp ChemoRadiation Protocols
• Paclitaxel (Taxol) and Carboplatin• Cisplatin and Fluorouracil (or
Capecitabine (Xeloda)• Oxaliplatin (Eloxatin) and Fluorouracil
![Page 55: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/55.jpg)
Chemotherapy
Metastatic Protocols
• DCF (docetaxel (Taxotere), cisplatin, fluorouracil
• ECF (epirubicin, oxaliplatin, fluorouracil)• Other drugs: trastuzumab (Herceptin),
irinotecan (Camptosar), Ramucirumab (VEGFR2)
![Page 56: Treatment of Cancer of the Esophagus](https://reader036.fdocuments.in/reader036/viewer/2022062307/5563cb59d8b42aa0588b4e4c/html5/thumbnails/56.jpg)
www.aboutcancer.com
Cancer of the EsophagusTreatment Options