Oesophagus Management Options Flashcards
What is the action for limited disease (T1,T2,N0,M0)?
- Resection surgery
- Easier if lower oesophagus
Who has FDG-PET/CT?
- Anyone eligible for resection, except T1a
- To avoid futile debilitating surgery (mets)
Why is nutritional support important?
- over 50% of patients lose >5% of body weight
- 40% lose >10% before admission for oesophagectomy
For localised GOJ adenocarcinoma what is the standard of care?
- Peri-operative chemotherapy
(cisplatin, oxaliplatin or carboplatin) Or capceitabeine/5FU 8-9 weeks - FLOT trial regimine
For resectable locally advanced SCC what is the standard of care?
- 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
Whar is the NeoAEGIS trial?
- 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
What is the surgical option for T1?
- Surgery or endocsopic resection
What is the surgical option for cT2N0?
- surgery alone (NO neoadj)
What is the surgical option for SCC?
- neoadj chemoRT followed by surgery and definitive chemotherapy are equally successful
What is the surgical option for locally advanced disease?
- surgery alone is not standard, complete resection cannot be achieved in many patients
- Long term survival generally lower than 20% even after surgery
What is Ivor Lewis oesophagectomy?
- 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
What is a minimally invasive oesophagectomy?
- 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
Who has definitive chemoRT?
- cervically localised tumours
- patients unable/unwilling to undergo surgery
What is the prescription for definitive chemoRT?
- 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%
When and how is definitive RT used?
- When surgery and chemotherapy are contraindicated
- 50 Gy in 15/16#
- 50-55 in 20#
- 60 Gy in 30#
- Not a lot of evidence
What are the effects of RT?
- 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
What did SCOPE2 trial show?
- Uses PET CT to identify high uptake regions
- Dose escalation for either chemo or RT to ty and improve outcomes
- reducing unnecessary treatment
What does follow up involve?
- No investigations
- It is about symptom management
How are palliative conditions managed?
- 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
How is brachytherapy used?
- 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
What chemo regimin is used to treat palliatively?
- platinum based and 5FU or capceitabeine.
- less proved in SCC
- no definitive remit for them, but they can be given
What forms of targeted therapies are available?
- monoclonal antibodies , man made antibodies to attack specific targets on cancer cells
- small-molecule drugs
- need to be specific because sepsis is a risk
When is herceptin used?
- HER2+, AC, metastatic
- administered weekly over 90 mins
- cardiotoxicity
What is the CRUCIAL trial?
- to assess feasibility and safety of nivolumab in inoperable patients with locally advanced oesophageal cancer