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Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

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Page 1: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

Moderators:David Cort, MDAlex Denes, MD

Panelists:Stephen Swisher, MD, PhD

Edward Lin, MD

Page 2: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

Tumor staging

T1- confined to mucosa/submucosa

T2- extends to muscularis propria

T3- extends into surrounding tissue

T4 - involves major vessels, pleura, pericardium

Nodal staging

N0 - no nodes involved

N1 - local nodes involved

N2 - distant nodes involved

Page 3: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

Esophagectomy

Combined modality Pre-operative chemo-radiation >>> esophagectomy Esophagectomy >>>> Post-operative chemo-radiation

Non surgical Definitive chemoradiation

Page 4: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

Surgical margins Pathology margins

R0 No tumor No tumor

R1 No tumor Microscopic tumor present

R2 Tumor present Macroscopic tumor present

Page 5: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

What are the usual sites of recurrence Local distant

Benefits Palliative chemo ± radiation

▪ survival benefit▪ Quality of life

Treatment of recurrence in lymph node outside the initial field of initial radiotherapy

How- Physical Exam- what signs to look for CT chest/abdomen- what findings to look for EGD – what symptoms should prompt it Serum CEA levels- ? In which patients EUS - ? role

How often Suggested protocols for follow up

Page 6: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD
Page 7: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

A 52 year old accountant with known history of Barrett’s esophagus and symptomatic reflux

surveillance endoscopy. 5 cm segment of Barrett’s esophagus proximal to the GE

junction. ▪ Biopsy - Multiple foci of HGD

1.5 cm sessile polypoid lesion at the GEJ▪ Biopsy- Invasive adenocarcinoma.

Page 8: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

T1- confined to the mucosa and submucosa and sparing the muscularis propria.

N0 – no enlarged lymph nodes

Page 9: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

PET/CT: No nodal or distant metastases

He undergoes esophagectomy without complications (R0 resection)

Surg path: T1, N0, (M0) moderately differentiated adenocarcinoma, No lympho-vascular infiltration multiple foci of Barrett’s all margins clear of tumor

Page 10: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

1. CT chest and abdomen every 3 months2. CT chest and abdomen every 6 months3. CXR every 3 months4. EGD every 3 months5. All of the above6. None of the above

AQ1. Appropriate post treatment follow-up of this patient would involve

Page 11: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

What are the chances of tumor recurrence

What are the usual sites of recurrence Local

▪ Treatment options▪ Benefits

Distant▪ Treatment options▪ Benefits

Suggested follow up after treatment

Page 12: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

T1N0 GEJ

The cure rate 80-90%.

If EMR or radiation cure rate 60-70% (then regular EGD is indicated).

Q 6 months for the first 2 years, then annual

physical exams with routine blood work.

Imaging only when clinically indicated.

Page 13: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

Repeat endoscopy 1 year after surgery to rule out residual Barrett’s or dysplasia

No CT Scan, CXR or PET scan unless symptoms because of low likelihood of distant mets with T1N0, LVI negative

Page 14: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

Repeat endoscopy 1 year after surgery to rule out residual Barrett’s or dysplasia

No CT Scan, CXR or PET scan unless symptoms because of low likelihood of distant mets with T1N0, LVI negative

Page 15: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD
Page 16: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

A 65 year old house-wife with history of GERD presents with progressive dysphagia

EGD: An irregular, non obstructing, ulcerated mass in the

distal esophagus. Biopsy: Moderately differentiated adenocarcinoma

EUS: T3 tumor (infiltrating muscularis propria) No enlarged lymph nodes

PET/CT: intense FDG uptake in the distal esophageal mass no lymph node or distant metastases

Page 17: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD
Page 18: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD
Page 19: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

Planned treatment: Pre-operative chemoradiation followed by surgery

Patient recieves combined modality therapy with radiation and chemotherapy Follow up EGD:

▪ no residual mass and biopsy shows only radiation effect.

Patient is now reluctant about proceeding with esophagectomy

Page 20: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

1. Convince the patient to proceed with surgery as originally planned

2. Give additional chemo-radiation to full dose

3. Can wait and see how the patient performs

4. None of the above

Page 21: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD
Page 22: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

RTOG-Hersovic: Chemo-RT > RT: 5-year 32%, vs 12% 20% vs 0% 10 year survival. LR > 45%

Intergroup 0123: 50.4 Gy > 64.8 Gy

Phase III: Modern RT = S

CMT vs S: OR 0.53-0.86. Three Meta-analysis (Ref 1-3). (Many small studies isolated positive study mostly with 5FU/Cisplatin/50.4 cGy.

Urschel Am J Surgery 2003:6:553. 1. Surgery 2005; 137:1727 2. Gut 2004;7:925 3. Walsh et la. NEJM.1997 Kelsen DP NEJM 1998; Yu ASCO 2006 Abst 4012

Page 23: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

Chances of tumor recurrence Sites of tumor recurrence

Local distant

Treatment options Salvage esophagectomy

Suggested follow up

Page 24: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

CT or CT/PET and endoscopy with biopsies q 3 months x2 then 6month x 3 then yearly (RTOG 0246) Early follow/up similar survival to

trimodality

Page 25: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

Esophagectomy R0 resection Path:

▪ No residual carcinoma in the esophagus ▪ 12 lymph nodes are clear

Page 26: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

What are the chances of tumor recurrence

What are the usual sites of recurrence Local

▪ Treatment options▪ Benefits

Distant▪ Treatment options▪ Benefits

Suggested follow up after treatment

Page 27: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

A 48 year old high school teacher presents with progressive dysphagia and weight loss

EGD: large ulcerated nearly circuferential mass in the lower third of

the esophagus. Biopsy: Moderate to poorly differentiated adenocarcinoma

with lymphovascular infiltration.

PET/CT: Intense FDG uptake in paraesophageal lymph nodes. No distant metastases.

EUS: T3 tumor (Nearly circumferential mass, extension into the

adventitia) N1 (multiple enlarged regional lymph nodes)

Page 28: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

T3N1 tumor

Page 29: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

Treatment: combined modality therapy with radiation and

chemotherapy.

Follow up EGD 75% regression of the mass. Biopsy: residual adenocarcinoma.

Esophagectomy R0 resection Path:

▪ Residual moderately differentiated adenocarcinoma, ▪ foci of carcinoma in 3 regional lymph nodes.

Page 30: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

1. Follow up with EGD and CT scan every 3 months

2. Follow up with EGD and CT scan every 6 months

3. Additional radiation therapy to maximal dose

4. Combination salvage chemoXRT

Page 31: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

What are the chances of tumor recurrence

What are the usual sites of recurrence Local

▪ Treatment options▪ Benefits

Distant▪ Treatment options▪ Benefits

Suggested follow up after treatment

Page 32: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

A 68 year old retired carpenter with a history of CAD, CABG, CHF, COPD, and DM presents with progressive GERD symptoms. No dysphagia or weight loss.

EGD: distal esophagitis with an area of ulceration just proximal

to the GE junction Biopsy: Moderately differentiated adenocarcinoma.

EUS: T2 N0tumor

Page 33: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

PET/CT: No abnormal FDG uptake in paraesophageal lymph

nodes. No distant metastases.

Surgical evaluation: Not candidate for resection due to co-morbidities

Treatment: Completes full course of combined chemotherapy and

radiation.

Page 34: Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

What are the chances of tumor recurrence

What are the usual sites of recurrence: 40% Local

▪ Treatment options: ▪ Benefits

Distant▪ Treatment options▪ Benefits

Suggested follow up after treatment


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