Esophageal Cancer Flashcards
For patients that require neoadjuvant therapy for esophageal cancer (those with tumors 3cm or higher or node + dx and/or high risk features e.g. poorly differentiated, LSVI what are the treatment options, what is preferred? This is for adenocarcinoma
Preoperative chemo/radiation therapy followed by surgery (this is Cat 1 preferred). You also have the option of perioperative chemo alone followed by surgery.
When can immunotherapy be used in the neoadjuvant setting for locally advanced esophageal cancer? What are the options? (tumors that are 3cm or more, and/or high risk features, and/or N+ dx).
For tumors that are MSI-H or dMMR
Options: Ipi/Nivo followed by Nivo, Pembro, and Tremelimumab/Durvalumab (neoadjuvant only)
What is the adjuvant therapy recommended for those patients that underwent chemo/RT followed by surgery and had less than a pCR but had a RO resection? This is for squamous and adenocarcinoma
Nivolumab which is associated with a DFS over placebo! (Cat 1). This is important to remember! The benefit was higher in those with a CPS>5. Also for those patients who only received chemo preoperatively then you give adjuvant chemo after surgery (Cat 1). Observation is an option too.
For those with a R1 resection following surgery what are the options after? R2 resection? This is for adenocarcinoma
R1: You can observe or give chemo/RT to those who didn’t receive RT to begin with. R2: chemo/RT only if they didn’t receive RT before.
For adenocarcinomas that undergo surgery upfront (no chemo/RT) what do you do if you have a R0 resection and pT2 or pT3/T4a? Node positive?
pT2-observation or chemo/RT (but this is a Cat 2B rec)
pT3/T4a and node+: observation, chemo/RT or chemo
For a R1 or R2 resection where surgery was done upfront with no chemo/RT what is the adjuvant tx needed after?
Chemo/RT
What are the tx options for for squamous cell carcinoma after undergoing preoperative chemo/RT and surgery and have a RO resection w/no residual dx or residual disease? R1/R2?
No residual dx-observation
Residual dx-Nivolumab
R1/R2-observation or palliative care
What are the tx options for a patient with squamous cell CA who did NOT have chemo/RT before surgery with a RO resection? R1 and R2?
R0-observation
R1-Chemo/RT
R2-chemo/RT or palliative care
Chemo-it will always be fluoropyrimidine based.
For squamous cell carcinoma with tumors that are 3cm or higher, and/or high risk features, and/or nodal involvement what are your treatment options?
Preoperative chemo/RT or definitive chemo/RT w/o surgery (very good option here) neither are listed as a Cat1 rec.
For patients with squamous cell CA who underwent preoperative chemo/RT what is the recommendation in those w/ no evidence of disease? What about for those who undergo def chemo/RT?
Preoperative chemo/RT w/no evidence of dx: observation (Cat2B) or esophagectomy.
Definitive chemo/RT w/no evidence of dx: observe. It says that you should do upper endoscopy and biopsy if surgery won’t be done!
In those with squamous cell who undergo preoperative chemo/RT and have residual dx what do you do? What about in those with residual dx after definitive chemo/RT?
Preoperative chemo/RT-resection
Definitive chemo/RT-resection.
What is the treatment for metastatic HER2+ esophageal cancer? For PDL-1 positive patients?
FOLFOX/CAPOX w/trastuzumab
PDL-1 w/CPS of 1 or higher: FOLFOX w/trastuzumab and pembrolizumab or you can do cisplatin as opposed to oxaliplatin
What is the tx of metastatic esophageal cancer that is HER2- and uses Nivolumab? What are the category recommendations depending on the CPS?
FOLFOX w/Nivolumab. CPS of 5 or more is a Cat 1 rec. CPS<5 is a Cat 2B rec.
What is the tx of metastatic Esophageal cancer that is HER2- and uses Pembro? What is the CPS cutoff for each category rec?
FOLFOX w/ Pembro. CPS of 10 or higher is a Cat 1 rec. CPS less than 10 is a Cat 2B rec.
Remember that you can combine Pembro w/5-FU and Cisplatin for metastatic HER2- esophageal cancer, but what is the CPS cutoff recommendation? Options w/o immunotherapy?
CPS of 10 or higher is a Cat 1 rec. Less than 10 is a Cat 2B rec. If you don’t want to use immunotherapy you can just do FOLFOX/CAPOX or exchange oxali for cisplatin alone.
