NCCN Esophageal Cancer

Question 1

Workup for esophageal cancer.

Answer 1

Upper GI and endoscopy. EUS.
CT chest and abdomen w/ oral and IV contrast.
Consider FDG PET.

Question 2

What extra lab/genetic workup is needed for esophageal cancer if metastatic disease is documented?

Answer 2

MSI and HER2.

Question 3

Esophageal cancer with tumor at or above the carina w/o evidence of metastasis requires what extra workup?

Answer 3

Bronchoscopy

Question 4

What important lifestyle modification is required for esophageal cancer patients?

Answer 4

Smoking cessation. Same with lung cancer pts.

Question 5

Esophageal SCC Stage I-IVA (except T4b or unresectable N3) assessment and next step?

Answer 5

Locoregional disease.
Requires multidisciplinary evaluation. Consider enteric feeding tube.
Assess for surgical candidacy (medical fitness and patient consent).

Question 6

Esophageal SCC pTis, pT1a, pT1b staging is defined via what workup?

Answer 6

Defined by pathology of diagnostic ER specimen. This may be therapeutic outright, but some may need additional therapy to start the surveillance.

Question 7

Esophageal SCC pTis preferred next step?

Answer 7

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.

Question 8

Esophageal SCC pT1a preferred next step?

Answer 8

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.

Question 9

Esophageal SCC pT1b N0 tx AND medically fit for surgery?

Answer 9

Esophagectomy

Question 10

Esophageal SCC s/p esophagectomy (no previous chemoradiation) w/ R1 or R2 resection next step?

Answer 10

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.

Question 11

Esophageal SCC cT1b-T2 N0 (low risk: <3cm, well differentiated; not cervical SCC) and medically fit for surgery preferred primary treatment option?

Answer 11

Esophagectomy

Question 12

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?

Answer 12

Preop chemoradiation, response assessment, then esophagectomy (can be possible to do surveillance if NED after response assessment).

Question 13

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?

Answer 13

definitive chemoradiation and follow up

Question 14

Esophageal SCC cT4b primary treatment option?

Answer 14

definitive chemoradiation; consider chemo alone if invades into trachea, great vessels, vertebral body, or heart

Question 15

What is the response assessment in medically fit patients with esophageal SCC s/p preoperative OR definitive chemoradiation?

Answer 15

FDG-PET/CT, upper GI and biopsy (can be omitted if planning on surgical intervention)

Question 16

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?

Answer 16

Esophagectomy is preferred, even after definitive chemoradiation (paclitaxel and carboplatin in CROSS trial).

Question 17

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?

Answer 17

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)

Question 18

What if during response assessment in medically fit patients with esophageal SCC s/p DEFINITIVE chemoradiation, a clinician discovers NO evidence of disease? IE is there additional management?

Answer 18

None. Surveillance.
This is different than finding persistent local disease, in which esophagectomy is preferred.

Question 19

What if during response assessment in medically fit patients with esophageal SCC s/p preoperative OR definitive chemoradiation, a clinician discovers unresectable disease or metastasis? What is the additional management?

Answer 19

Palliative management

Question 20

An esophageal SCC patient has not received preoperative chemoradiation, and surgical outcome is R0, what should be done for postop management?

Answer 20

Surveillance.
ANY T. ANY N.
Don’t add anything unless R1 or R2.

Question 21

In esophageal SCC patients who have NOT received preop chemoradiation who have an R1 or R2 outcome after esophagectomy, what is the base of for the chemo (part of chemoradiation)?

Answer 21

Fluoropyrimidine

Question 22

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?

Answer 22

Surveillance

Question 23

Esophageal SCC pt s/p chemoradiation AND esophagectomy is found to have R0 resection. Tumor classification is ANYTHING BUT yp T0 N0. What is added to postop management?

Answer 23

Nivolumab

Question 24

Esophageal SCC pt s/p chemoradiation AND esophagectomy is found to have R1 or R2 resection, what is the postop management?

Answer 24

observation until progression or palliative management

Question 25

How do you manage pTis esophageal SCC in medically UNFIT patients?

Answer 25

ER, ER followed by ablation, or ablation; then endoscopic surveillance.
Lots of endoscopic options.

Question 26

How do you manage pT1a esophageal SCC in medically UNFIT patients?

Answer 26

ER or ER followed by ablation, then endoscopic surveillance.
As opposed to pTis, cannot do ablation alone.

Question 27

How do you manage pT1b esophageal SCC in medically UNFIT patients?

Answer 27

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.

Question 28

How do you manage >pT1b or N+ esophageal SCC in medically UNFIT patients?

Answer 28

Figure out what they can tolerate, and offer it:
Definitive chemoradiation, palliative RT, or palliation then follow up.

Question 29

What is follow up/surveillance for esophageal SCC?

Answer 29

H&P w/ increasing intervals and nutritional assessment and counseling.
The rest is as clinically indicated: CMP and CBC, upper GI and bx.

IE no routine EGD or CT scans.

Question 30

During follow up/surveillance for esophageal SCC, anastomotic stenosis is found w/o evidence of cancer, what can be done?

Answer 30

Dilation

Question 31

During follow up/surveillance for esophageal SCC s/p esophagectomy WITHOUT chemoradiation, locoregional recurrence is found, what is next preferred?
What are other options?

Answer 31

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.

Question 32

During follow up/surveillance for esophageal SCC s/p chemoradiation ONLY, locoregional recurrence is found, what is next?

Answer 32

Assess medical fitness.
Can do esophagectomy if anatomically feasible and able.
Assess response w/ CT chest and abdomen w/ contrast.
If second recurrence, palliate.

Question 33

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?

Answer 33

palliative management

Question 34

During follow up/surveillance for esophageal SCC, regardless of treatment, metastatic disease is found, what is the management?

Answer 34

palliative

Question 35

Pt w/ esophageal SCC has unresectable locally adv disease, locally recurrent, or metastatic disease, what are the treatment options?
What factors into decision making?

Answer 35

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.

Question 36

For R side NSCLC, an adequate mediastinal lymphadenectomy includes what stations?

Answer 36

2R, 4R, 7, 8, 9

Question 37

For L side NSCLC, what stations constitute an adequate lymph node staging?

Answer 37

4L, 5, 6, 7, 8, 9

Question 38

Are there any differences in surgical management between SCC and adenocarcinoma for esophageal cancer for T1b?

Answer 38

For superficial pT1b ADENOCARCINOMA, ER followed by ablation can be offered vs esophagectomy.
For T1b esophageal SCC, ONLY esophagectomy is offered.

Question 39

For esophageal cancer, is there any treatment difference b/w adeno and SCC for cT2,N0 high-risk, N+, or T3-T4a?

Answer 39

For ADENO, perioperative or preoperative chemotherapy (ie WITHOUT chemoradiation) can be offered before esophagectomy.

Question 40

For esophageal adenocarcinoma or SCC, what are the options for cT4b?

Answer 40

Definitive chemoradiation.
Chemotherapy alone can be considered in settings of organs that cannot be radiated (trachea, great, vessels, vertebral body, heart).

Question 41

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?

Answer 41

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.

Question 42

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?

Answer 42

Nivolumab (same as SCC).

Ie if the neoadj did not wipe out the tumor, give nivolumab for more systemic effect.

Question 43

In what situation can re-resection of an R1 resection esophageal cancer be done?

Answer 43

Can be considered only if ADENOCARCINOMA (ie NOT SCC).
Otherwise, healthy and tumor able to be resected from a technical standpoint.

Question 44

After ER for early esophageal cancer (up to select superficial pT1b [adeno]) in the setting of Barrett, what should be done with the rest of the Barrett esophagus?

Answer 44

Ablative therapy of residual Barrett.

Question 45

In relation to the cricopharyngeus (UES), what would be considered a resectable esophageal cancer?

Answer 45

> 5 cm below cricopharyngeus (UES). Usually below the sternal notch.
The 5 cm b/w the UES and the sternal notch is considered the cervical esophagus.

Question 46

How do you manage esophageal cancer with an epicenter 2.1 cm distal to the EGJ?

Answer 46

Like gastric cancer. This is Siewert Type III.

Question 47

For esophageal cancers, does N+ disease found at staging exclude from surgical candidacy?

Answer 47

No.
Only resectable w/ N+ if T1-T3.
Bulky, multi-station lymphatic involvement is a relative contraindication.

Question 48

What esophageal T4a tumors are resectable?

Answer 48

Pericardium, pleura, diaphragm

Question 49

An esophageal cancer patient has a positive supraclavicular node that is positive. Can you resect?

Answer 49

No.
Pt’s w/ distant (including nonregional lymph nodes) or metastasis (stage IV) are unresectable.

*NCCN: Patients with EGJ and supraclavicular lymph node involvement should be considered unresectable.

Question 50

What are acceptable conduits for esophageal resection? What is preferred?

Answer 50

Gastric (preferred), colon, jejunum.

Question 51

An esoph ca pt undergoes definitive chemoradiation, and on follow-up/surveillance is found to have localized resectable cancer (and is medically operable). Can they be considered for esophagectomy?

Answer 51

Yes. SCC and adenocarcinoma.

Question 52

In esoph ca pts requiring esophagectomy w/o induction chemo, how many nodes should be removed to provide adequate nodal staging?

Answer 52

15. These would be T1b pts.

Question 53

For systemic therapy for esophageal cancer, what can be added for HER2 overexpression?

Answer 53

Trastuzumab.
HER2, MSI, and PD-L1 testing should be tested if metastatic disease is documented or suspected.