oesophagus Flashcards
What are the risk factors for oesophageal adenoca
Typically distal oesophagus
GORD
Obesity
Reflux & Barretts
What are the risk factors for oesophageal SCC
Typically proximal oesophagus
Alcohol, smoking
What are the investigations for a potential oesophageal cancer
Assess local disease:
OGD & biopsy
EUS for nodal assessment
+/- bronchoscopy if threat of tracheal invasion / involvement
Assess distant disease:
CTCAP
PET (if considering radical treatment)
Laparoscopy to exclude peritoneal mets (in GOJ or T3/4 tumours)
What is the frequency of follow up OGD for surveillance of dysplasia on biopsy
No dysplasia: OGD every 2-3 years
LG dysplasia: OGD every 6 months
HG dysplasia: discuss in MDT – resect vs surveillance
What molecular markers are sent for a metastatic oesophageal cancer
PDL1, MMR and HER2
PDL1 - CPS >10, or TPS >1%
How is a T1 oesophageal cancer defined
Invasion into mucosa
How is a T2 oesophageal cancer defined
Muscular invasion - muscularis propia
How is a T3 oesophageal cancer defined
Invasion into adventitia
How is a T4 oesophageal cancer categorised and defined
Resectable local invasion - 4a - pleura, pericardium, diaphragm, peritoneum
Non-resectable local invasion - 4b - aorta, trachea vertebrae
How is nodal staging defined for oesophageal cancer
N1 - 1-2 nodes
N2 - 3-6 nodes
N3 - ≥7 nodes
When is endoscopic surgery indicated for oesophageal cancer
T1N0 disease, and <2cm, <1/3 oesophageal circumference, non-ulcerated, well diff cancer
What is the treatment regime for a T2-4 or node positive oesophageal adenocarcinoma
Neoadjuvant FLOT x4 cycles, followed by surgery and adjuvant FLOT
What is the regimen for neoadjuvant CRT for oesophageal SCC or adenocarcinoma
Weekly carboplatin (AUC2)/paclitaxel (50mg/m2) x5 with 41.4Gy/23# RT
CROSS trial demonstrated improved R0 resection and benefit in mOS (SCC better than adeno)
What are the types of oesophagectomy and when are they indicated
2 stage - Ivor-Lewis, with en bloc two field lymphadenectomy - for mid/lower 1/3 oesophageal cancer
3 - stage - McKeown - for proximal cancers
When is definitive CRT for oesophageal cancer indicated
Surgery is SOC
CRT indicated if:
Pt declines surgery
Pt not fit for surgery
Local disease precludes, ie unlikely to achieve an R0 resection
What is the chemoRT regimen for oesophageal cancer
How does CRT compare to surgery
4 cycles of 3wkly cisplatin (75mg/m2 - D1) & 5FU (1000mg/m2 - D1-4)
OR 3wkly cisplatin (60mg/m2 - D1) & bd capecitabine (625mg/m2) throughout treatment
RT given with cycles 3 & 4
50Gy/25# (or 50.4Gy/28#)
Local control rates better with surgery, but equivalent overall survival
ESOPEC trial is investigating neoadjuvant FLOT vs CRT
When is adjuvant nivolumab indicated for oesophageal cancer
What was the benefit
Only following trimodality treatment, ie chemoRT and surgery, where there is residual disease on pathology, either for SCC or adeno
1yr adjuvant nivolumab, no PDL1 status needed
Improved DFS from 11mths to 22.4 and reduction in risk of death
When is radical RT alone indicated and what is the dose
when not fit for surgery or CRT
Dose:
If <5cm - 50Gy/16#
If >5cm - 55Gy/20#
What is the maximal oesophageal tumour length that can be treated with RT
17cm - 10-12cm tumour and nodes, + margin
What is the GTVp & GTVn
What is the GTV-CTV margin and what else is included in the CTV?
What is the CTV-PTV margin
GTVp - Tumour + nodes within 3cm
GTVn - nodes >3cm from primary
CTV - GTVp +2cm sup/inf, or GTVn +1cm (whichever is greater), then 1cm radially
If GOJ involvement - extend CTV to 2cm below GTV
CTV also includes elective nodal regions, gastrohepatic ligament, paracardial and left gastric LNs
CTV-PTV margin - 1cm sup/inf & 0.5cm radially
What are the OAR dose constraints for oesophageal RT - lung
Lungs - V20Gy < 25%
What is the treatment given to a HER2+ metastatic oesophageal adenocarcinoma
Trastuzumab with cis-cape / carbo-cape / cap-ox
What palliative RT can be given to oesophageal cancer
What volume
20 in 5 or 30 in 10, for dysphagia or bleeding
CTV - GTV +3cm sup/inf
PTV - CTV +1.5cm all around, and 7mm for field edge if field based RT
6MV POP
What is the prognosis for radically treated oesophageal cancer
Radical surgery
T1/2 N0 - 50%
T3/4 or N1-3 - 20%
Radical RT - 20%
CRT - 30%
What are the OAR dose constraints for oesophageal RT - heart
V40Gy<30%
What are the OAR dose constraints for oesophageal RT - kidneys
Mean <18Gy
Ipsi V20 <40%
Contra V20 <25%
What are the OAR dose constraints for oesophageal RT - spinal cord
objective <48Gy, constraint <50Gy
What are the OAR dose constraints for oesophageal RT - liver
V30Gy<60%
What are the OAR dose constraints for oesophageal RT - spleen
<10Gy mean
How is PDL1 status categorised for metastatic oesophageal SCC
how does this determine management
SCC
PDL1 ≥10 (CPS)
PDL1 TPS ≥1% but CPS <10
PDL1 negative
PDL1 ≥10 (CPS) - pembro + ChT (Pt/FP)
PDL1 TPS ≥1% but CPS <10 - Nivolumab-ChT
PDL1 negative - ChT only, nivolumab 2nd line (no PDL1 requirement)
Taxane or irinotecan on progression
How is PDL1 status categorised for metastatic oesophageal adenocarcinoma
how does this determine management
Adeno
PDL1 ≥10 (CPS)
PDL1 CPS 5-10
PDL1 negative (CPS <5)
PDL1 ≥10 (CPS) - Pt/FP + pembro or nivo
PDL1 CPS 5-10 - Nivolumab-ChT
PDL1 negative (CPS <5) - Pt/FP ChT (or carboplatin/paclitaxel if FP intolerant)
