Management Of Esophageal Ca

General Principal

  • Only 20% can be considered for curable treatment (truly localized)
    • 80% —> locally advanced or distant disease.

Options for early esophageal Ca

  • Endoscopic Mucosal Resection and Ablation
  • Esophagectomy

Surgery

  • Subtotal or total esophagectomy
    • Mid to lower third of the thoracic esophagus & GEJ
    • Stage I to III and selected IVa tumors
  • Different techniques
    • Transhiatal esophagectomy
      • Removing the esophagus through the diaphragmatic hiatus
      • Without opening the chest
      • Upper abdominal incision + 2 left neck incisions
      • Free the esophagus from both side
      • Moving the stomach upward through the hiatus and into the chest until its upper end appears in the neck wound
      • Cervical esophagogastric anastomosis (CEGA)
      • Advantages:
        • Less lung complications (especially pneumonia)
          • Avoid mediastinitis
        • Less pain as chest is not opened
        • Easier access to anastomotic leak if happens
          • It is in the neck versus thorax
        • Less morbid
      • Disadvantages:
        • No direct visualization for LN dissection
        • Anastomotic tension is high
          • Chance of anastomotic leak
    • Right thoracotomy (Ivor-Lewis)
      • 1st a laparotomy is done
        • Release of stomach
      • Then a right side thoracic approach
      • For mid and lower third
      • Advantages
        • More extensive lymph node dissection
        • Less Anastamotic tension
          • Lower leak rate
        • Direct and better visualization Dissection
        • Avoid neck morbidity
      • Disadvanrages
        • May exacerbate pulmonary dysfunction
        • Thoracic Leak
        • More peri-op mortality
    • Left thoracotomy
      • For GEJ lesiosn
    • Radical esophagectomy
  • Reconstruction options:
    • Esophagogastrostomy
      • Most widely used
      • That is why, that if possible surgery is planned, gastric tube placement is generally avoided given the stomach will ultimately serve as the “neoesophagus” following resection
    • Colon interposition
      • Usually left colon
      • Not common

For cervical Esophageal ca —> Resection of portions of the pharynx, the entire larynx, thyroid gland, and the proximal esophagus+ radical neck dissections —> very morbid —> ChemoRT

Results of Surgery Alone

  • Removes the tumor and lymph nodes
  • Local-regional relapse is a common mode of failure
    • 30-50%
  • 5yr OS —> 12%
    • Node negative: 30%
    • Node positive: 7%

Pre-OP therapy

Pre-OP RT

  • Potential advantages
    • Increased resectability of tumors
    • Increased tumor radioresponsiveness secondary to improved tumor oxygenation
    • Theoretical decreased likelihood of dissemination at the time of surgery
    • Avoidance of surgery in patients with rapidly progressive disease.
  • 5 randomized trial and one meta-analysis
  • No clear benefit in OS, LR, DM
    • Actually pre-op RT is detrimental.

Pre-OP Chemo

  • 3 randomized trial and one meta-analysis
  • No clear benefit
    • One trial showed survival benefit
      • 40% vs 30%

Pre-OP ChemoRT

  • Improves:
    • OS
    • Margin negative resection rates
    • LR
  • ~30% CR
  • Probabely 3yr survival —> 30% vs 15%

Post-OP Therapy

Post-OP RT

  • Advantages:
    • Knowledge of the pathological staging
      • ==> appropriately select patients for therapy
        • Spare patients with T1N0 or metastatic ca
    • May allow the radiation oncologist to treat areas at risk for recurrence while sparing otherwise normal radiosensitive structures
  • Disadvantages:
    • Limited tolerance of normal tissues
      • Gastric pull-up or intestinal interposition
      • Irradiation of a devascularized tumor bed
  • 3 randomized trails
  • May decrease local recurrence, particularly with involved margins
  • No clear benefit on OS

Post-OP CRT

  • Appropriate in GEJ
  • Increase median survival from 27m to 36m(?)

Palliative Treatment

  • Resection and reconstruction
    • Resolve dysphagia
    • May prevent:
      • Abscess and fistula formation
      • Bleeding
    • Survival —> 2-6m
  • Endoscopic dilatation
    • Dilation to 15 mm
    • Repeat dilatation is often required
  • Esophageal stenting
    • Plastic stents
    • Metallic self-expanding stents
  • Palliative RT
    • 30Gy/10 to 50Gy/25
    • Resolution of symptoms in 80% of patients
  • Palliative Chemo

Curative Combination Therapy

Radiation Therapy Alone versus Chemoradiation

Landmark trial —> RTOG 8501

Outcome RT 64Gy CRT 50Gy+5FU-Cis
Median Survival 9m 12m
5yr Survival 0% 30%
LR 70% 45%
DM 45% 25%
Life-threating side effects* 3% 20%

*Hematologic toxicity & fistula formation

Local failure and survival rates appear similar between “definitive” chemoradiation and surgical approaches.

Surgery following CRT

  • French and German Study
  • Improves local control but had no impact on overall survival
  • Nonresponders to induction chemotherapy may benefit from surgery, and it may be appropriate to individualize therapy based on response to induction treatment

Chemotherapy regimen in radical CRT

  • 5-fluorouracil (5-FU)
    • 1000 mg/m2 d1-4 during wk 1 and 5
  • Cisplatin
    • 75 mg/m2 d1 during wk 1 and 5

Radiation Technique

  • 50.4Gy in 28fr (1.8Gy/fr)
  • CTV1 = GTV + 4 cm superior and inferior and 1 cm radial
  • CTV2 = GTV + 2 cm superior and inferior and 0.5 cm radial
  • PTV = CTV + 1 cm superior and inferior and 0.5 cm radial
  • PTV1 = 39.6 Gy, PTV2 = 50.4 Gy in 1.8 GPF

Esophageal Ca Treatment Planning