Editing Oesophageal cancer (section)

= '''MANAGEMENT''' =

== '''Initial considerations''' ==

* Curative or palliative intent
* Fitness for surgery
* Resectable
* Choice of neoadjuvant     treatment

== '''General stage-based approach''' ==

* As of 2024, no consensus on     whether to treat SCC and AC any differently
* '''Pre-treatment     optimisation is vital'''
** Nutritional assessment and      management, including enteral access if required - NGT through tumour on      diagnosis if unable to tolerate pureed/solids. 60% of newly-diagnosed      upper GI cancer have malnutrition.
** Management of other      comorbidities
* Mucosa-only cancer ('''TisN0M0''' and '''HGD''') - intensive surveillance vs     endoscopic ablation vs oesophagectomy
** See separate topic under      'Barrett's oesophagus'
** Current best option probably      endoscopic in the first instance
* '''T1aN0M0'''
** Only 2% lymph node mets (not      much lymphoid tissue in lamina propria/muscularis mucosae)
** Can usually be treated with      EMR
*** Better with lesions <2cm
*** Indicated in nodular or       raised Barrett's or other findings suspicious of superficial invasive       cancer
*** Resects down to submucosa
*** Does not address the       potential for nodal disease (need to assess risk of nodal mets using       nomogram above)
** Higher-risk T1a lesions      (larger tumours or lymphovascular invasion) or extensive multifocal      lesions/ulcerated tumours could be considered for oesophagectomy
* '''T1bN0M0''' - oesophagectomy generally     best due to abundance of lymphoid tissue in the submucosa
** Up to 20% lymph node      metastasis risk - probably should go back and do oesophagectomy if this      is the final EMR diagnosis
** However low-risk sm1 may be      able to have oesophagus-sparing therapy, with 84% five-year survival rate
*** Needs intense high-dose       PPI, H2 blockers, and sucralfat, with 3-monthly endoscopy for the first       year
** EMR not considered adequate      for sm2 and above due to risk of missing nodal mets
** Generally, give neoadjuvant      therapy
* '''T2-4a''', any N, M0 ('locally     advanced')
** Easy to get locoregional      control with oesophagectomy, but rates of death from distant recurrence      or metastasis continue to be high
** Neoadjuvant CTX followed by      surgery 5-7 weeks later is best strategy
** Restage with CT after CTX
** Clinical T2N0 is somewhat      controversial
*** Many have node-positive       disease in histopathology after oesophagectomy
*** One strategy is to       selectively offer neoadjuvant CTX based on the pretest probability of       upstaging (long tumours >3cm, presence of lymphovascular invasion,       and high-grade tumours indicate likely to upstage)
* '''T4b or any     M1''' - palliative     - consider palliative chemoradiotherapy
** Endoscopic palliation -      self-expanding stents

== '''Neoadjuvant/adjuvant therapy''' ==

* Consider everything >     stage I (non-superficial) cancers for multimodality therapy
** T2-T4
** Nodal involvement with no      mets
* Regime choices/trials
** '''MAGIC''' trial (2006) demonstrated      advantage to neoadjuvant chemotherapy
*** '''NEOAGIS''' didn't show much       difference between MAGIC CTX and CROSS CRT
** '''CROSS''' - chemoradiotherapy -      weekly carboplatin and paclitaxel for five weeks, with concurrent 41.4Gy      radiotherapy in 23 fractions - better tolerated than FLOT, used for      patients with comorbidities or poor performance status
*** Landmark trial was the '''CROSS''' trial - 366 patients, R0       in neoadjuvant CRTx was 92% vs 69% for up-front surgery, and double the       median survival (49 vs 24 months)
** '''FLOT-'''4 trial - chemotherapy      5-fluorouacil, folinic acid, oxaliplatin, and docetaxel for three cycles,      then surgery, then another three cycles - perhaps this is the best      neoadjuvant CTx for adenocarcinoma - can be hard to tolerate for      comorbid/frail patients, with mortality 2%
*** '''ESOPEC''' 2024 trial showed an       advantage to FLOT over CROSS in terms of long-term survival
** '''CHECKMATE577''' - CROSS vs CROSS followed      by adjuvant nivolumab immunotherapy - best results for SCC - give as      adjuvant if did not achieve complete response - especially good for SCC.
*** Should we also be using it       in complete response, to treat microscopic distant disease?
** '''TOPGEAR''' - Australian trial which      showed no benefit to neoadjuvant radiotherapy
**
* It's not really known what to     do with patients who initially have surgery but are then found to have     pathological indications for chemoradiotherapy
** May reduce local recurrence      in patients with T4 or node positive tumours who didn't have CTX/RTX      initially
* Chemotherapy
** Usually downstages      marginally resectable tumours, allowing improved R0 rates
** Decreases the rate of      locoregional recurrence
** Current regimes based      cisplatin/carboplatin and 5-fluorouacil/taxanes
** Both adenocarcinoma and SCC      patients experience a benefit
** Much better survival with      neoadjuvant compared to adjuvant CTX
** Synergistic effect with RTX
* Immunotherapy
** Usually nivolumab which is a      checkpoint inhibitor with anti-PD-L1 activity
** Start adjuvant immunotherapy      12/52 post op, if indicated based on presence of residual disease
** Duration 1 year
** SCC or adenocarcinoma
** Improved median disease-free      survival from 11 to 22 months
* Radiotherapy
** 50.4 Gy of radiation used      concomitantly with CTX is both a neoadjuvant and potentially definitive      dose
* Definitive chemoradiotherapy     can be curative
** Can do RTx + FOLFOX, CROSS      or fluorouracil/cisplatin
** Need surveillance, and      salvage therapy if recurrence is found
** 98% of local recurrences      occur in first 36 months - suggest vigilant surveillance for this period
** Combination of clinical      examination, gastroscopy and CT +/- PET
** SCC is more likely than AC      to achieve complete response based on definitive CRT, but there isn't yet      consensus on indications for CRT vs surgery in those patients. If      complete endoscopic and radiological response has been achieved for      oesophageal SCC after CRT, likely appropriate to observe.

== '''Early cancers''' ==

* Use this diagram to     subclassify depth of invasion of superficial cancers
* M1, M2 and M3 are reasonable     candidates for endoscopic resection, if no evidence of lymphovascular     invasion
** If M3 with lymphovascular      invasion, treat as T1b
** If recurrence/positive      margins, needs oesophagectomy
* All submucosal tumours (T1b)     should have oesophagectomy with therapeutic lymphadenopathy

== '''Recurrent cancers''' ==

* Not much evidence for or     against salvage oesophagectomy after CRT, but can be done in the knowledge     that risks are higher and systemic cure not guaranteed
* Resection of oligometastatic     disease should be carefully considered, taking disease tempo and ECOG     status into account

== '''Palliation''' ==

* Poor performance status or     metastases or unresectable cancers
* Checkpoint inhibitors have     given good results as palliative CTX
* Endoscopic options based on     symptoms

== '''Prognosis:''' ==

* 5-year survival:
** Tis 90%
** pT1 75%
** pT2 45%
** pT3 30%
** pT4 15%
* Overall 5 year survival 23.7%
* Adenocarcinoma
**
* SCC
**


[[Category:UGIS]]