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Esophageal carcinoma > Background and recommendations > Flashcards

Background and recommendations Flashcards

1
Q

Typical path CR rates after preop CRT?

A

16-38%

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2
Q

Is there a role of preop RT alone?

A

No, multiple studies indicate that there is no benefit to giving RT alone before surgery

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3
Q

Stage IV (adeno)

A

TxMx M1

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4
Q

Stage I (adeno)

A

IA: T1 N0 G1-2

IB: T1 N0 G3 or T2 N0 M0 G1-2

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5
Q

Stage II (adeno)

A

IIA: T2 N0, G3

IIB: T3 N0 or T1-2 N1, Any G

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6
Q

Stage III (adeno)

A

IIIA: T1-2 N2 or T3 N1 M0 or T4a N0

IIIB: T3 N2

IIIC: T4a N1-2, T4b or N3

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7
Q

What is the optimal number of nodes that should be removed at esophagectomy?

A

23

Peyre CG, Ann Surgery

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8
Q

T3

A

Invades adventitia

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9
Q

T4b

A

Invasion of other organs including the aorta, vertebral body, trachea

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10
Q

T2

A

Invades muscularis propria

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11
Q

T1a

A

Invasion of the lamina propria

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12
Q

T1b

A

Invasion of submucosa

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13
Q

Tis

A

high grade dysplasia or CIS

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14
Q

T4a

A

Pleural, pericardial or diaphragm involvement

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15
Q

In the history, what do you want to ask about?

A

Sx: indigestion, hoarseness of voice, dysphagia, odynophagia, pain, cough, dyspnea, weight loss and loss of appetite, melana, hematemesis

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16
Q

Treatment paradigm for SCCa of the cervical esophagus?

A

Definitive CRT with IMRT and 5FU/cisplatin to 60-66 Gy

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17
Q

Spinal cord constraint?

A

Max dose 45 Gy

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18
Q

Follow up schedule for patients treated with EMR or other ablative procedures?

A

H&P + endoscopy every 3 months for 1 year

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19
Q

Criteria for EMR?

A 
Tis/T1a
No ulceration 
Tumor < 2 cm 
Well to moderately differentiated 
No LVI
No ulceration
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20
Q

What is the 5 year OS for patients managed with preop CRT and surgery who have a CR or near CR?

A

5 year OS 60-70%

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21
Q

What is the 5 year OS for patients managed with surgery alone for T1 N0?

A

5 year OS of 77%

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22
Q

What is the treatment paradigm for patients with T2 or node positive, non-metastatic disease?

A

Neoadjuvant CRT followed by esophagectomy

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23
Q

How is esophageal cancer defined at endoscopy based on location?

A

Esophageal tumors are usually atleast 15 cm from the incisors and can extend to the GE junction and the proximal 5 cm of the stomach

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24
Q

What imaging and labs are needed for work up?

A

Imaging: PET/CT scan with diagnostic CT of the chest and abdomen/pelvis
Labs: CMP including LFTs and alk phos, BMP

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25
Q

What special studies are needed in work up?

A
  1. EGD with EUS and biopsy
  2. Bronchoscopy upper upper/mid thoracic lesions to rule out tracheoesophageal fistula
  3. PFTs
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26
Q

What labs are needed at work up?

A

CBC, LFTs, CEA, BMP

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27
Q

What is the PE at work up?

A

LN exam: cervical, supraclavicular
Abdominal exam
Respiratory exam

28
Q

What counseling is needed?

A

Nutrition assessment

29
Q

What are the types of esophagectomies?

A

Transhiatal
Right thoracotomy: Ivor-Lewis
Left thoracotomy
Radical resection

30
Q

Treatment for Stage T2 or N+?

A

Preop CRT with 50.4 Gy of RT concurrent with 5FU and cisplatin followed by esophagectomy and node dissection

31
Q

What is the expected OS and LF after prep-CRT and surgery?

A

3 year OS: 20-30%

3 year LF: 45%

32
Q

What is the preferred treatment for T1b N0?

A

Esophagectomy and node dissection

33
Q

Indications for PORT

A

Node positive
T3/4
Close or positive margin
Unfavorable T2 N0 (LVSI, poorly differentiated)

34
Q

What is the preferred treatment for inoperable patients

A

CRT with 50.4 Gy of RT concurrent with 5FU and cisplatin

35
Q

What are some palliative RT doses?

A

30 Gy in 10 fractions, provide 4 Gy/fx initially for bleeding
35 Gy in 14 fractions

36
Q

CT simulation

A 
Supine 
Arms Up 
Indexed bag
Esophotrast 
4D scan for distant esophageal tumors
37
Q

Describe RT volumes

A

GTV: gross tumor and nodes as seen on EGD and CT scan/PET scan
CTV: GTV + 4 cm sup and inf and 1 cm radial. Include SCV nodes and mediastinal nodes for tumors above carina. Include celiac nodes for tumors near the GE junction.

PTV: 0.5

38
Q

Expected acute side effects of CRT

A
  1. Esophagitis
  2. Weight loss
  3. Fatigue
  4. Anorexia
39
Q

Subacute side effects of CRT

A
  1. Pneumonitis
40
Q

Late side effects of CRT

A

Esophageal strictures
Pericarditis
CAD

41
Q

Follow up after CRT and surgery

A

H&P every 4 months for 1 year, then very 6 months for 4 more years, then annually

42
Q

Nodal stage

A

N1: Metastasis to 1-2 nodes
N2: Metastasis to 3-6 nodes
N3: Seven or more regional nodes

43
Q

M stage

A

M1: distant metastasis

44
Q

Stage IV: Squamous cell carcinoma

A

M1

45
Q

Stage III: SCCa

A

IIIA: T1-2 N2 or T3 N1 or T4a N0
IIIB: T3 N2
IIIC: T4a N1-2 or N3 or T4b

46
Q

Stage II: SCCa

A

IIA:
T2-3 N0 Grade 1, X (Upper or middle)

T2-3 N0 M0 Grade 2,3 (Lower)

Stage IIB:
T2-3 N0 Grade 2-3 (Upper or middle)

T1-2 N1 M0 Any Grade (Any location)p

47
Q

Stage I: SCCa

A

IA: T1 N0 M0 Grade 1, X (Any location)

IB:
T1 N0 M0 Grade 2-3 (Any location)
T2-3 N0 M0 Grade 1,X (Lower, X)

48
Q

What are some esophageal constraints for stricture?

A

Data from Emami

V60<100%

49
Q

Heart constraint?

A

V40<30%

50
Q

What dose of cisplatin and 5FU?

A

Cisplatin 75 mg/m2

5FU 1000 mg/m2 x 4d

51
Q

What study supports CRT vs. RT alone?

A

RTOG 8501
RT vs. CRT
CRT improved 2 year OS

52
Q

What is the risk for LF with CRT alone?

A

47-58%

53
Q

What study examined CRT +/- surgery for SCCa of the upper to middle esophagus? What was the result?

A

German Esophgeal Cancer Study Group

Results: Overall no difference but in non-responders, surgery improved 3 year OS to 32%

54
Q

What study showed improvement in OS for patients treated with Preop CRT + surgery vs. surgery alone? What did it show?

A

CROSS Phase III
Improvement of 23 months in median OS
CRT improved R0 resection rates from 67% to 92%
CR rate of 29%

55
Q

What is the path CR rate following CRT?

A

16% to 29%

56
Q

What study evaluated preop chemo vs. preop CRT for T3-4 GE junction tumors?

A

the POET trial

Pre surgery cisplatin/etoposide + RT vs.

57
Q

Liver constraints?

A

Mean < 25 Gy

V30 < 60%

58
Q

Kidney constraints

A

Mean < 18 Gy

59
Q

Which study supports the use of IMRT?

A

MDAH Lin et al Red Journal 2012

Lowee OS with 3D conformal due to cardiac and undocumented deaths being higher

60
Q

Lung constraints?

A

V20<30%

61
Q

5 year OS for patients treated with Preop CRT + surgery?

A

30-40%

62
Q

What distance is the cervical esophagus from the incisors?

A

15-20 cm

63
Q

What distance is the upper thoracic esophagus from the incisors?

A

20-25 cm

64
Q

What distance is the middle thoracic esophagus from the incisors?

A

25 to 30 cm

65
Q

What distance is the lower thoracic esophagus from the incisors?

A

30-40 cm

66
Q

What alternative chemo regimen is there?

A

Carboplatin AUC 2 IV on day 1
Txaol 50 mg/m2 IV on day 1
weekly for 5 weeks

67
Q

The GEJ is a marker of two different mucosal surfaces? What are they? What is the transition called?

A
  1. Squamous esophageal
  2. Gastric columnar
  3. The Z line

Esophageal carcinoma (1 decks)

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