Multimodality Therapy in Esophageal Cancer Flashcards
What is the difference between induction therapy and neoadjuvant therapy?
Induction therapy specifically refers to chemotherapy given before radiation therapy, whereas neoadjuvant therapy can refer to any treatment given before surgery
risk factors for esophageal squamous cell carcinoma
Use of tobacco
alcohol
betel quid
ingestion of very hot liquids
and some genetic predisposition
risk factors for esophageal adenocarcinoma
Gastroesophageal reflux disease (GERD)
Barrett’s esophagus
and obesity, with no clearly defined genetic predisposition
Which esophageal cancer patients are recommended for neoadjuvant multimodal therapy?
at least clinical T3 disease or clinical N1 disease
Why is neoadjuvant multimodal treatment for clinical T2N0 esophageal cancer controversial?
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
What factors support upstaging T2N0 esophageal cancer and the use of neoadjuvant therapy?
Tumor length ≥ 3 cm
poorly differentiated histology
evidence of lymphovascular invasion on biopsy
Treatment algorithm for adenocarcinoma and squamous cell carcinoma
PIC
What is the current standard multimodal treatment for esophageal adenocarcinoma and gastroesophageal junction adenocarcinoma
Concurrent perioperative chemotherapy and radiotherapy
What chemotherapy regimen showed superiority in the FLOT4 trial compared to the MAGIC protocol?
Four preoperative and postoperative cycles of FLOT (docetaxel, oxaliplatin, leucovorin, and 5-FU) increased median survival from 35 to 50 months.
Which histologic subtype showed a more pronounced response to neoadjuvant chemoradiotherapy in the CROSS trial?
Squamous cell carcinoma showed a higher rate of pathologic complete response compared to adenocarcinoma.
What neoadjuvant regimen was used in the NEOCRTEC5010 trial? Cross Trial, for Squamous
Two cycles of vinorelbine and cisplatin delivered concurrently with 40 Gray of radiation in 20 fractions
What are common targets of immunotherapy agents?
Programmed cell death protein 1 (PD-1) and programmed cell death ligand 1 (PD-L1).
What is PD-1, and where is it expressed
PD-1 is a cell surface receptor expressed on activated immune cells, including T cells, B cells, and myeloid cells.
What is the role of PD-L1 in cancer cells?
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
How do immunotherapy agents targeting PD-1 or PD-L1 work?
They block the immune checkpoint, reactivating T cells to attack cancer cells
Name three monoclonal antibodies that target PD-1.
Nivolumab
pembrolizumab
toripalimab
Name three monoclonal antibodies that target PD-L1
Atezolizumab
avelumab
durvalumab
What are common immunotherapy-related toxicities?
Autoimmune responses affecting the gastrointestinal tract, skin, endocrine glands, and liver.
What are some less common but serious immune-related adverse events from immunotherapy?
Myocarditis, pneumonitis, and central nervous system disorders
How are serious immunotherapy-related toxicities typically managed?
Cessation of immunotherapy and treatment with glucocorticoids
How does the site of oligometastatic disease affect survival outcomes?
Improved survival is associated with lung metastasis, whereas brain or liver metastasis has poorer outcomes
What factors limit a patient’s ability to complete multimodal treatment for esophageal cancer and increase postoperative risks?
Frailty, sarcopenia, malnutrition, and symptomatic dysphagia.
How does total neoadjuvant therapy benefit patients with locally advanced esophageal cancer?
It eliminates treatment delays from postoperative complications and increases the likelihood of achieving a complete pathologic response
What is the concept of prehabilitation in the treatment of esophageal cancer?
Prehabilitation involves pre-treatment “training” with aerobic, strength-based, and inspiratory muscle exercises to improve patient fitness for major surgery.
Why are gastric feeding tubes generally avoided in the preoperative setting for esophageal cancer patients?
Because the stomach is most often used as the conduit for reconstruction after esophagectomy.
What is a common alternative for nutritional supplementation in esophageal cancer patients who need it preoperatively or postoperatively?
Jejunal feeding tube placement.
What are less desirable alternatives to jejunal feeding tubes for nutritional support in esophageal cancer patients?
Total parenteral nutrition (TPN) and nasoenteral feeding tubes
What treatment modalities were found to improve progression-free and overall survival in patients with oligometastatic disease
Radiotherapy or chemoembolization
What did Port et al. demonstrate regarding the treatment of recurrent nodal or oligometastatic solid organ metastasis in esophageal cancer?
Prolonged survival in patients who underwent surgical resection followed by adjuvant chemoradiation compared to definitive chemoradiation alone
