Esophageal Cancer FRCR CO2A Flashcards
At what length esophagus extends from central incisor?
15 to 40 cm
Sternal notch, carina and GE Jxn distance from central incisor
18 cm
25 cm
40 cm
Malignant tumors of esophagus
AC 65%
Sq 25%
small cell
lymphoma
melanoma etc
sievert classification
Type I: esophageal
Type II esophageal and Gastric
Type III: Gastric
RFs for Esophageal Cancer
GORD
Alcohol
Smoking
Corrosives
Reduced dietary Vit C
malnutrition
Possible infective causes of esophageal cancer
- H. Pylori
- HPV
- Fungally infected cereals
Associated conditions with Ca Esophagus
Barrett’s esophagus (1 % lifetime risk of developing an AC)
others
Achalasia
Tylosis palmaris
Celiac Disease
Plummer Vinson Syndrome
Apart from GORT and Barrets, others are a/w sq cell carcinoma
sequence from metaplasia to dysplasia and invasive adenocarcinoma
molecular changes
loss of TP53 function
loss of heterozygosity (LOH) of Rb gene
over expression of cyclins D1 and E
inactivation of p16 and p27
Amplification of MYC and k and H RAS
local spread of esophageal cancer
no peri esophageal serosa to inhibit their growth, skip lesions and mediastinal structures infiltration into the trachea, aorta, pleura, diaphragm and vertebrae
Lymphatic spread of Esophageal Cancer
N1: supraclavicular, upper, middle and lower para esophageal, rt and lt paratracheal, aorto pulmonary, subcarinal, diaphragmatic; paracardial; left gastric, common hepatic, splenic artery and coeliac
M1 LNs
upper third to celiac and
lower third to supraclavicular
metastatic spread of esophageal cancer
Liver and lungs
Grades of Dysphagia
G1: difficulty with some food such as bread and meat
G2: able to eat a soft diet
G3: only liquid diet
G4: Complete dysphagia
where does patient point for different location of obstruction in esophagus?
sternal notch if upper level
epigastric if lower level
Investigations for esophageal cancer
FBC
Biochemical Profile
Diagnostic Endoscopy and Biopsy
EUS
PET Scan
Advantages of EUS:
- staging the primary, disease length
when in esophageal cancer PET scan most useful
patient suitable for radical treatment
to prevent unnecessary surgery in 20 % of cases
when is Bronchoscopy useful
above the carina tumors or signs of T4 disease
Staging:
as per TNM
Early Esophageal Cancer (T1 or T2, N0) treatment
Surgical Resection is Rx of choice
CRT may play a role if the patient is not fit enough
EMR (Endoscopic Mucosal Resection) Indication
Early Cancers < 2 cm, non ulcerated, well differentiated cancers
premalignant condition such as high grade dysplasia
superficial esophageal cancers
once the submucosa is breached, EMR would not be treatment of choice, due to increased chances of LN involvement
RFA indications in Ca Esophagus
more diffuse high grade dysplasia
Treatment of locally advanced Esophageal Cancer
Neoadjuvant Therapy f/b surgery
Sq Cell Carcinoma >T1b or N+
Pre op CRT f/b Surgery or
Definitive CRT
post op RT indication
R1 or R2 resection
Surgeries for Ca Esophagus
- Ivor Lewis
- En Bloc
- total thoracic, three stages (McKeown)
- Transhiatal approach
Ivor Lewis Surgery
Two Stage:
laparotomy and celiac LND
Right Thoracotomy for mobilisation and resection and mediastinal lymphadenectomy along with intrathoracic anastomosis
Post op ChT or Post op RT
No evidence of its use
Ajuvant RT: for R1
Pre OP Chemotherapy
IN THE UK, two cycles of cisplatin and 5 FU given before surgery
MAGIC trial
either perioperative chemotherapy and surgery (250 patients) or surgery alone (253 patients).
Chemotherapy consisted of three preoperative and three postoperative cycles of intravenous epirubicin (50 mg per square meter of body-surface area) and cisplatin (60 mg per square meter) on day 1, and a continuous intravenous infusion of fluorouracil (200 mg per square meter per day) for 21 days.
As compared with the surgery group, the perioperative-chemotherapy group had a higher likelihood of overall survival (hazard ratio for death, 0.75; 95 percent confidence interval, 0.60 to 0.93; P=0.009; five-year survival rate, 36 percent vs. 23 percent) and of progression-free survival (hazard ratio for progression, 0.66; 95 percent confidence interval, 0.53 to 0.81; P<0.001).
Pre OP CRT Rationale
CRM positivity after radical resection alone is high (> 50% in T3 tumors)
CROSS Trial
DUTCH trial
NACRT f/b Sx Vs Sx alone
Doubling of OS for NACRT f/b Sx
Definitive CRT Indications:
inoperable for medical reasons,
or unlikely R0 resection possible
who decline Surgery
Upper third Cervical Esophagus distance from incisor
15 to 18 cm
Middle Third, from incisor
18 to 31 cm
Lower Third, to GO junction
31 to 40 cm
How can pts with upper third tumors be treated?
Like H & N cancer Patients, such as post cricoid carcinoma
Planning for Esophageal Cancer
4D planning preferred
in supine position with arms above their hands and immobilisation of the legs with knee fix
anter and two lateral fiducials
slice thickness 3 mm
IV contrast can be given to distinguish the GTV from surrounding tissues
Target Delineation in UK is based on which trial
SCOPE 1
GTV contouring
with the help from diagnostic CT scan, PET CT scan and EUS
why is EUS better for GTV delineation?
submucosal spread is better identified
CTV expansion
2 cm craniocaudally , 1 cm radially, edited for structures such as vertebrae that do not need to be incorportated in CTV, particularly if there is potential to impact on organs OARs, eg the spinal cord
what to include if tumor involves GE junction?
The Gastrohepatic ligament region
CTV to PTV margin
1 cm, can be different as per institute’s protocol
Dose Constraints as per SCOPE 1
Sp COrd PRV, D40 Gy = 0 %
Heart, V 40 Gy < 30 %
Lung V 20 Gy < 25%
Liver V 30 Gy < 60%
Individual Kidney V20 < 25%
RT Doses
Definitive RT alone: 60 to 64 Gy, 2 Gy/#
CRT: 50 Gy/ 25#
pre operative CRT, 45 Gy/ 25#
Constraint for PTV
PTV V95 > 95 % but less than 107%
Conc Chemotherapy
Cisplatin and Capecitabine or 5 FU
Common regimen : 4 three weekly cycles, RT in cycles 3 and 4
Recurrent Ca Esophagus Treatment
Prognosis: Very Poor
palliative Chemotherapy
if anastomotic recurrence and no mets on PET, dCRT
After dCRT recurrence, palliative Stent placement
M1 Ca esophagus, Adenocarcinoma
Systemic Therapy NCCN 2025
depends on HER 2 expression and PDL1 status and MSI/MMR status
Adenocarcinoma esophagus
what if Her 2 overexpression and PDL1 CPS >/= 1
FOLFOX/CAPEOX + Trastuzumab + Pembrolizumab
Adenocarcinoma Esophagus
if dMMR/MSI - H
Pembrolizumab
Dostarlimab
Nivo and Ipilimumab
Adenocarcinoma Esophagus
what if Her 2 negative and PDL1 CPS >/= 1
FOLFOX/CAPEOX + Pembrolizumab or Nivolumab
Adenocarcinoma Esophagus
Cytotoxic chemotherapies in ca esophagus
Paclitaxel with or without carboplatin or cisplatin
Docetaxel with or without cisplatini
M1 Squamous Cell Carcinoma Esophagus Regimens
same as adenocarcinoma except for Her2
Palliative Endoscopic Rx Options in Ca Esophagus
- Stents
- Endoscopic laser thermal Nd-YAG or photodynamic therapy (PDT)
- Dilation
- Alcohol Injection
Palliative RT dose
30 Gy/ 10 #
40 Gy/ 15#
Small Cell Esophageal Cancer Rx
CRT (chemo Cisplatin Etoposide)
ILT dose
15 Gy at 1 cm with HDR microselectron
SCOPE 1 trial
dCRT in localized esophageal cancer in UK and investigated adding cetuximab to standard cisplatin and 5 FU treatment
Disease control and survival in standard dCRT arm better
