Oesophagus Management Options

Question 1

What is the action for limited disease (T1,T2,N0,M0)?

Answer 1

• Resection surgery

- Easier if lower oesophagus

Question 2

Who has FDG-PET/CT?

Answer 2

• Anyone eligible for resection, except T1a

- To avoid futile debilitating surgery (mets)

Question 3

Why is nutritional support important?

Answer 3

• over 50% of patients lose >5% of body weight

- 40% lose >10% before admission for oesophagectomy

Question 4

For localised GOJ adenocarcinoma what is the standard of care?

Answer 4

• Peri-operative chemotherapy
  (cisplatin, oxaliplatin or carboplatin) Or capceitabeine/5FU 8-9 weeks
• FLOT trial regimine

Question 5

For resectable locally advanced SCC what is the standard of care?

Answer 5

• Neo-adj chemoRT
• 45Gy in 25#/5 weeks (neoscope trial)

or

• Neo-adj chemoRT (Cross trial)
• 41.4 Gy in 23#/4.5 weeks with carboplatin and paclitaxel

Question 6

Whar is the NeoAEGIS trial?

Answer 6

• Neo-adj ChemoRT vs neo-adj chemo
• T2-3 N0-1 M0
• Arm 1 followed MAGIC or FLOT pre-and post surgery
• Arm 2 chemoRfollowed CROSS 4.5 weeks RT (41.4Gy/23) with carboplatin and paclitaxel

Question 7

What is the surgical option for T1?

Answer 7

• Surgery or endocsopic resection

Question 8

What is the surgical option for cT2N0?

Answer 8

• surgery alone (NO neoadj)

Question 9

What is the surgical option for SCC?

Answer 9

• neoadj chemoRT followed by surgery and definitive chemotherapy are equally successful

Question 10

What is the surgical option for locally advanced disease?

Answer 10

• surgery alone is not standard, complete resection cannot be achieved in many patients
• Long term survival generally lower than 20% even after surgery

Question 11

What is Ivor Lewis oesophagectomy?

Answer 11

• hybrid of two approaches
• laparotomy incision to allow for mobilisation of the stomach
• A right sided throacotomy for excision and resection of the oesophagus
• open laparotomy allows for good abdo exporusre and wider lymph disection
• big op with complications

Question 12

What is a minimally invasive oesophagectomy?

Answer 12

• Keyhole
• total or partial excision
• same result as open but with less morbidity
• Less surgery related morbidity with same clinical outcomes
• No evidence for recurrence rate or in-hospital rates compared with open
• better physical functioning

Question 13

Who has definitive chemoRT?

Answer 13

• cervically localised tumours

- patients unable/unwilling to undergo surgery

Question 14

What is the prescription for definitive chemoRT?

Answer 14

• 50Gy in 25
• 50.4 in 28
• with carboplatin and 5FU
• RTOG-85-01 trial looked at dose escalation (64Gy) but survival was worse. Survival 27 v 0%

Question 15

When and how is definitive RT used?

Answer 15

• When surgery and chemotherapy are contraindicated
• 50 Gy in 15/16#
• 50-55 in 20#
• 60 Gy in 30#
• Not a lot of evidence

Question 16

What are the effects of RT?

Answer 16

• oesophagitis (usually around 3rd week)
• Swallowing difficulties
• Skin reaction
• Late effects include oesphpgeal fistula, stricture, haemorrage, radiation pneumonitis and pericarditis
• Late complications of radical RT may include fibrosis

Question 17

What did SCOPE2 trial show?

Answer 17

• Uses PET CT to identify high uptake regions
• Dose escalation for either chemo or RT to ty and improve outcomes
• reducing unnecessary treatment

Question 18

What does follow up involve?

Answer 18

• No investigations

- It is about symptom management

Question 19

How are palliative conditions managed?

Answer 19

• consider chemoradiotherapy if no mets
• or chemotherapy alone
• look at best supportive care

-RT = 30/10#, 35/15#, 20/5#, 40/15# - reduce bleeding or symptoms

Question 20

How is brachytherapy used?

Answer 20

• intra-luminal brachy
• palliative
• used less now due to the use of IMRT (integrated boost)
• 5-20Gy at 1cm depth
• 12 Gy in 1 or 12-16Gy in 2 fractions
• risk of fistula formation
• is useful in helping with dysphasia in the long term

Question 21

What chemo regimin is used to treat palliatively?

Answer 21

• platinum based and 5FU or capceitabeine.
• less proved in SCC
• no definitive remit for them, but they can be given

Question 22

What forms of targeted therapies are available?

Answer 22

• monoclonal antibodies , man made antibodies to attack specific targets on cancer cells
• small-molecule drugs
• need to be specific because sepsis is a risk

Question 23

When is herceptin used?

Answer 23

• HER2+, AC, metastatic
• administered weekly over 90 mins
• cardiotoxicity

Question 24

What is the CRUCIAL trial?

Answer 24

• to assess feasibility and safety of nivolumab in inoperable patients with locally advanced oesophageal cancer