NCCN Esophageal Cancer Flashcards
Workup for esophageal cancer.
Upper GI and endoscopy. EUS.
CT chest and abdomen w/ oral and IV contrast.
Consider FDG PET.
What extra lab/genetic workup is needed for esophageal cancer if metastatic disease is documented?
MSI and HER2.
Esophageal cancer with tumor at or above the carina w/o evidence of metastasis requires what extra workup?
Bronchoscopy
What important lifestyle modification is required for esophageal cancer patients?
Smoking cessation
Esophageal SCC Stage I-IVA (except T4b or unresectable N3) assessment and next step?
Locoregional disease.
Requires multidisciplinary evaluation. Consider enteric feeding tube.
Assess for surgical candidacy (medical fitness and patient consent).
Esophageal SCC pTis, pT1a, pT1b are defined via what workup?
Defined by pathology of diagnostic ER specimen. This may be therapeutic outright, but some may need additional therapy to start the surveillance.
Esophageal SCC pTis preferred next step?
Endoscopic therapies: ER, ER and ablation, only ablation. Then endoscopic surveillance. *Can be done for cervical lesions.
Esophagectomy is an option, but not preferred.
Same as pT1a.
Esophageal SCC pT1a preferred next step?
Endoscopic therapy: ER, or ER followed by ablation. Then endoscopic surveillance. *Can be done for cervical lesions.
Esophagectomy is an option as well, but not preferred.
This is same for pTis.
Esophageal SCC pT1b N0 tx AND medically fit for surgery?
Esophagectomy
Esophageal SCC s/p esophagectomy (no previous chemoradiation) w/ R1 or R2 resection next step?
Chemoradiation.
Setting would be lesions Tis and T1a that opted for esophagectomy rather than endoscopy and ended up w/ microscopic or gross positive margins; or up to cT2 N0 lesions that are low risk (<3cm, well differentiated; not cervical) that got esophagectomy w/ positive margins.
Esophageal SCC cT1b-T2 N0 (low risk: <3cm, well differentiated; not cervical SCC) and medically fit for surgery preferred primary treatment option?
Esophagectomy
Esophageal SCC cT2 N0 but high risk (LVI, 3cm or more, poorly differentiated),
cT3-cT4a,
or any N+,
AND NOT cervical…
Primary treatment option for medically fit patient?
Preop chemoradiation, response assessment, then esophagectomy (can be possible to do surveillance if NED after response assessment).
Esophageal SCC in cervical esophagus that is either cT2 and high risk (3cm or more, LVI, or poorly differentiated), N+, or cT3 or greater primary treatment option?
definitive chemoradiation and follow up
Esophageal SCC cT4b primary treatment option?
definitive chemoradiation; consider chemo alone if invades into trachea, great vessels, vertebral body, or heart
What is the response assessment in medically fit patients with esophageal SCC s/p preoperative OR definitive chemoradiation?
FDG-PET/CT, upper GI and biopsy (can be omitted if planning on surgical intervention)
What if during response assessment in medically fit patients with esophageal SCC s/p chemoradiation (preop or definitive), a clinician discovers persistent local disease? What is the additional management?
Esophagectomy is preferred, even for definitive chemoradiation
What if during response assessment in medically fit patients with esophageal SCC s/p PREOPERATIVE chemoradiation, a clinician discovers NO evidence of disease? What is the additional management?
Esophagectomy, but surveillance can be chosen.
If surveillance chosen, need to have upper GI and biopsy to confirm (can be omitted if surgery is planned)
What if during response assessment in medically fit patients with esophageal SCC s/p DEFINITIVE chemoradiation, a clinician discovers NO evidence of disease? What is the additional management?
None. Surveillance.
This is different than finding persistent local disease, in which esophagectomy is preferred.
What if during response assessment in medically fit patients with esophageal SCC s/p preoperative OR definitive chemoradiation, a clinician discovers unresectable or metastasis? What is the additional management?
Palliative management
An esophageal SCC patient has not received preoperative chemoradiation, and surgical outcome is R0, what should be done for postop management?
Surveillance.
ANY T. ANY N.
Don’t add anything unless R1 or R2.
In esophageal SCC patients who have NOT received preop chemoradiation who have an R1 or R2 outcome after esophagectomy, what is the basis of chemoradiation?
Fluoropyrimidine
Esophageal SCC pt s/p chemoradiation AND esophagectomy is found to have R0 resection. Tumor classification is yp T0 N0. What is the postop management?
Surveillance
Esophageal SCC pt s/p chemoradiation AND esophagectomy is found to have R0 resection. Tumor classification is ANYTHING BUT yp T0 N0. What is the postop management?
Nivolumab
Esophageal SCC pt s/p chemoradiation AND esophagectomy is found to have R1 or R2 resection, what is the postop management?
observation until progression or palliative management
How do you manage pTis esophageal SCC in medically UNFIT patients?
ER, ER followed by ablation, or ablation; then endoscopic surveillance.
Lots of endoscopic options.
How do you manage pT1a esophageal SCC in medically UNFIT patients?
ER or ER followed by ablation, then endoscopic surveillance.
As opposed to pTis, cannot do ablation alone.
How do you manage pT1b esophageal SCC in medically UNFIT patients?
ER or ER followed by ablation, then endoscopic surveillance.
The difference b/w pT1b and pT1a, is that with pT1b, you can add definitive chemoradiation IF the patient has poor prognostic features:
LVI, poorly differentiated, 2cm or more (not 3cm, which is used for surgical assessment), positive margins.
The difference b/w pT1b for medically unfit patients is that endoscopic therapy can be offered, as opposed to esophagectomy, which would be ideal.
How do you manage >pT1b or N+ esophageal SCC in medically UNFIT patients?
Figure out what they can tolerate, and offer it:
Definitive chemoradiation, palliative RT, or palliation then follow up.
What is follow up/surveillance for esophageal SCC?
H&P w/ increasing intervals and nutritional assessment and counseling.
The rest is as clinically indicated: CMP and CBC, upper GI and bx.
During follow up/surveillance for esophageal SCC, anastomotic stenosis is found w/o evidence of cancer, what can be done?
Dilation
During follow up/surveillance for esophageal SCC s/p esophagectomy WITHOUT chemoradiation, locoregional recurrence is found, what is next?
Concurrent chemoradiation is preferred.
Chemotherapy alone is an option. (Second) Surgery is an option. Or can do palliative/best supportive care.
Response assess w/ CT chest and abdomen w/ contrast.
Recurrence again means palliative.
During follow up/surveillance for esophageal SCC s/p chemoradiation ONLY, locoregional recurrence is found, what is next?
Assess medical fitness.
Can do esophagectomy if anatomically feasible and able.
Assess response w/ CT chest and abdomen w/ contrast.
If second recurrence, palliate.
During follow up/surveillance for esophageal SCC s/p chemoradiation ONLY, locoregional recurrence is found but it is unresectable and/or patient is not medically fit, what is next?
palliative management
During follow up/surveillance for esophageal SCC, regardless of treatment, metastatic disease is found, what is the management?
palliative
Pt w/ esophageal SCC has unresectable locally adv disease, locally recurrent, or metastatic disease, what should be done?
Determine performance status:
If Karnofsky performance 60% or > or ECOG 2 or less => microsatellite and PD-L1 testing for systemic therapy.
Otherwise palliative/best supportive care.
For R side NSCLC, an adequate mediastinal lymphadenectomy includes what stations?
2R, 4R, 7, 8, 9
For L side NSCLC, what stations constitute an adequate lymph node staging?
4L, 5, 6, 7, 8, 9
Are there any differences in surgical management between SCC and adenocarcinoma for esophageal cancer for T1b?
For superficial pT1b ADENOCARCINOMA, ER followed by ablation can be offered vs esophagectomy.
For T1b esophageal SCC, ONLY esophagectomy is offered.
For esophageal cancer, is there any treatment difference b/w adeno and SCC for cT2,N0 high-risk, N+, or T3-T4a?
For ADENO, perioperative or preoperative chemotherapy (ie WITHOUT chemoradiation) can be offered before esophagectomy.
For esophageal adenocarcinoma or SCC, what are the options for cT4b?
Definitive chemoradiation.
Chemotherapy alone can be considered in settings of organs that cannot be radiated (trachea, great, vessels, vertebral body, heart).
Are there differences in post-surgical treatment between SCC and adenocarcinoma (depending on R status of resection) for pts who HAVE NOT received preop chemo or chemoradx?
R0 for SCC - no matter the T or N, all move to surveillance (focus of SCC is a good resx).
R0 for adenocarcinoma - T2 and above or any N+ should be considered for chemoradiation (similar req to neoadj, except this case no neoadj was given).
R1 gets chemoradiation for either.
R2 gets chemoradiation or palliative for either.
For esophageal adenocarcinoma s/p preop chemorad w/ R0 resection and ypT+ and/or N+ disease, what can be added to treatment for postop management?
Nivolumab (same as SCC).
Ie if the neoadj did not wipe out the tumor, given nivolumab for more systemic effect.
Can re-resection of an R1 resection esophageal cancer be done?
Only if adenocarcinoma (ie NOT SCC).
After ER for early esophageal cancer (up to select superficial pT1b [adeno]), what should be done with the rest of the esophagus?
Ablative therapy of residual Barrett.
In relation to the cricopharyngeus, what would be considered a resectable esophageal cancer?
> 5 cm below cricopharyngeus.
How do you manage esophageal cancer with an epicenter 2.1 cm from the EGJ?
Like gastric cancer. This is Siewert Type III.
For esophageal cancers, does N+ disease found at staging exclude from surgical candidacy?
No.
Only resectable w/ N+ if T1-T3.
Bulky, multi-station lymphatic involvement is a relative contraindication.
What esophageal T4a tumors are resectable?
Pericardium, pleura, diaphragm
An esophageal cancer patient has a positive supraclavicular node that is positive. Can you resect?
No.
Pt’s w/ distant (including nonregional lymph nodes) or metastasis (stage IV) are unresectable.
What are acceptable conduits for esophageal resection? What is preferred?
Gastric (preferred), colon, jejunum.
An esoph ca pt undergoes definitive chemoradiation, and afterwards is found to have localized resectable cancer. Can they be considered for esophagectomy?
Yes.
In esoph ca pts requiring esophagectomy w/o induction chemo, how many nodes should be removed to provide adequate nodal staging?
15.
These would be T1b pts.
For systemic therapy for esophageal cancer, what can be added for HER2 overexpression?
trastuzumab
