Multimodality Therapy in Esophageal Cancer

Question 1

What is the difference between induction therapy and neoadjuvant therapy?

Answer 1

Induction therapy specifically refers to chemotherapy given before radiation therapy, whereas neoadjuvant therapy can refer to any treatment given before surgery

Question 2

risk factors for esophageal squamous cell carcinoma

Answer 2

Use of tobacco
alcohol
betel quid
ingestion of very hot liquids
and some genetic predisposition

Question 3

risk factors for esophageal adenocarcinoma

Answer 3

Gastroesophageal reflux disease (GERD)
Barrett’s esophagus
and obesity, with no clearly defined genetic predisposition

Question 4

Which esophageal cancer patients are recommended for neoadjuvant multimodal therapy?

Answer 4

at least clinical T3 disease or clinical N1 disease

Question 5

Why is neoadjuvant multimodal treatment for clinical T2N0 esophageal cancer controversial?

Answer 5

Up to 50% of patients with clinical T2 disease have occult nodal disease not identified on staging CT-PET, and the benefit of neoadjuvant therapy depends on the presence of nodal disease

Question 6

What factors support upstaging T2N0 esophageal cancer and the use of neoadjuvant therapy?

Answer 6

Tumor length ≥ 3 cm
poorly differentiated histology
evidence of lymphovascular invasion on biopsy

Question 7

Treatment algorithm for adenocarcinoma and squamous cell carcinoma

Answer 7

PIC

Question 8

What is the current standard multimodal treatment for esophageal adenocarcinoma and gastroesophageal junction adenocarcinoma

Answer 8

Concurrent perioperative chemotherapy and radiotherapy

Question 9

What chemotherapy regimen showed superiority in the FLOT4 trial compared to the MAGIC protocol?

Answer 9

Four preoperative and postoperative cycles of FLOT (docetaxel, oxaliplatin, leucovorin, and 5-FU) increased median survival from 35 to 50 months.

Question 10

Which histologic subtype showed a more pronounced response to neoadjuvant chemoradiotherapy in the CROSS trial?

Answer 10

Squamous cell carcinoma showed a higher rate of pathologic complete response compared to adenocarcinoma.

Question 11

What neoadjuvant regimen was used in the NEOCRTEC5010 trial? Cross Trial, for Squamous

Answer 11

Two cycles of vinorelbine and cisplatin delivered concurrently with 40 Gray of radiation in 20 fractions

Question 12

What are common targets of immunotherapy agents?

Answer 12

Programmed cell death protein 1 (PD-1) and programmed cell death ligand 1 (PD-L1).

Question 13

What is PD-1, and where is it expressed

Answer 13

PD-1 is a cell surface receptor expressed on activated immune cells, including T cells, B cells, and myeloid cells.

Question 14

What is the role of PD-L1 in cancer cells?

Answer 14

PD-L1 is expressed on the surface of some cancer cells to trigger immune evasion by activating the immune checkpoint when it binds to PD-1

Question 15

How do immunotherapy agents targeting PD-1 or PD-L1 work?

Answer 15

They block the immune checkpoint, reactivating T cells to attack cancer cells

Question 16

Name three monoclonal antibodies that target PD-1.

Answer 16

Nivolumab
pembrolizumab
toripalimab

Question 17

Name three monoclonal antibodies that target PD-L1

Answer 17

Atezolizumab
avelumab
durvalumab

Question 18

What are common immunotherapy-related toxicities?

Answer 18

Autoimmune responses affecting the gastrointestinal tract, skin, endocrine glands, and liver.

Question 19

What are some less common but serious immune-related adverse events from immunotherapy?

Answer 19

Myocarditis, pneumonitis, and central nervous system disorders

Question 20

How are serious immunotherapy-related toxicities typically managed?

Answer 20

Cessation of immunotherapy and treatment with glucocorticoids

Question 21

How does the site of oligometastatic disease affect survival outcomes?

Answer 21

Improved survival is associated with lung metastasis, whereas brain or liver metastasis has poorer outcomes

Question 22

What factors limit a patient’s ability to complete multimodal treatment for esophageal cancer and increase postoperative risks?

Answer 22

Frailty, sarcopenia, malnutrition, and symptomatic dysphagia.

Question 23

How does total neoadjuvant therapy benefit patients with locally advanced esophageal cancer?

Answer 23

It eliminates treatment delays from postoperative complications and increases the likelihood of achieving a complete pathologic response

Question 24

What is the concept of prehabilitation in the treatment of esophageal cancer?

Answer 24

Prehabilitation involves pre-treatment “training” with aerobic, strength-based, and inspiratory muscle exercises to improve patient fitness for major surgery.

Question 25

Why are gastric feeding tubes generally avoided in the preoperative setting for esophageal cancer patients?

Answer 25

Because the stomach is most often used as the conduit for reconstruction after esophagectomy.

Question 26

What is a common alternative for nutritional supplementation in esophageal cancer patients who need it preoperatively or postoperatively?

Answer 26

Jejunal feeding tube placement.

Question 27

What are less desirable alternatives to jejunal feeding tubes for nutritional support in esophageal cancer patients?

Answer 27

Total parenteral nutrition (TPN) and nasoenteral feeding tubes

Question 28

What treatment modalities were found to improve progression-free and overall survival in patients with oligometastatic disease

Answer 28

Radiotherapy or chemoembolization

Question 29

What did Port et al. demonstrate regarding the treatment of recurrent nodal or oligometastatic solid organ metastasis in esophageal cancer?

Answer 29

Prolonged survival in patients who underwent surgical resection followed by adjuvant chemoradiation compared to definitive chemoradiation alone