Editing Oesophageal cancer (section)

== '''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.