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Carcinoma esophagus

Basic discussion regarding anatomy to management of a case of Carcinoma Esophagus

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Carcinoma esophagus

  1. 1. Carcinoma Esophagus Presented By: Dr. Ayush Garg
  2. 2. AJCC TNM classification ❚ a: Includes nodes previously labeled as “M1a” ❚ b : “M1a” designation is no longer recognized in the 7th edn. of the AJCC system
  3. 3. Staging : Squamous cell carcinoma
  4. 4. Staging : Adenocarcinoma Group T N M Grade 0 Tis (HGD) N0 M0 1, X IA T1 1-2, X IB T1 3 T2 1-2, X IIA T2 3 IIB T3 T1-2 N1 IIIA T1-2 N2 T3 N1 T4a N0 Any IIIB T3 N2 IIIC T4a N1-2 T4b Any Any N3 IV Any Any M1
  5. 5. Diagnostic Workup ❚ Detailed history & Physical examination: Dysphagia, odynophagia, hoarseness, wt. loss, use of tobacco, nitrosamines, history of GERD. Examine for cervical or supraclavicular adenopathy. ❚ Confirmation of diagnosis: ❙ EGD: allow direct visualization and biopsy, measure proximal & distal distance of tumor from incisor, presence of Barrett’s esophagus. Early, superficial cancer Circumferential ulceration esophageal cancer Malignant stricture of esophagus
  6. 6. ❚Staging: ❙ CT chest and abdomen: Essential for staging because it can identify extension beyond the esophageal wall, enlarged lymph nodes and visceral metastases. Figure Esophageal cancer with tracheal invasion. CT scan shows circumferential wall thickening of the proximal esophagus (arrowheads), which shows irregular interface with the posterior wall of the trachea (arrows), indicating direct extension into the lumen Figure Esophageal cancer with aortic invasion. An arc (bent arrow) of the contact between esophageal cancer (arrows) and the the aorta (arrowheads) is more than 90 degrees, indicating aortic invasion.
  7. 7. Endoscopic Ultrasonography ❚ EUS: ❙ assess the depth of penetration and LN involvement. Limited by the degree of obstruction. ❙ Compared with EUS, CT is not a reliable tool for evaluation of the extent of tumor in the esophageal wall. Fig. —55-year-old man with T2 esophageal tumor (m) shown on endoscopic sonogram. Note alternating hyperechoic and hypoechoic layers (arrowheads) of normal esophageal wall as seen on sonography. Innermost layer is hyperechoic and corresponds to superficial mucosa. Second layer is hypoechoic and corresponds to deep mucosa and muscularis mucosae. Third layer is again hyperechoic and corresponds to submucosa and its interface with muscularis propria. Fourth layer is hypoechoic and corresponds to muscularis propria, and outer fifth layer is hyperechoic and corresponds to adventitia.
  8. 8. PET Scan ❚ most recently, proven to be valuable staging tool ❚ can detect up to 15–20% of metastases not seen on CT and EUS ❚ low accuracy in detecting local nodal disease compared to CT / EUS ❚ Value in evaluating response to Chemo Therapy & Radio Therapy ❚ addition of PET to CT can improve specificity and accuracy of non- invasive staging Figure Distant lymph node metastases of esophageal cancer detected by integrated CT PET. A, Integrated CT PET demonstrates para-aortic lymph node metastases showing increased FDG uptake (arrowheads). B, Corresponding CT image shows lymph nodes (arrowheads) measuring 5 to 8 mm in diameter. Based on size criteria, these lymph nodes may be considered benign on CT scan
  9. 9. ❚ Barium swallow: ❙ can delineate proximal and distal margins as well as TEF ❙ Helpful for correlation with simulation film. ❚ Bronchoscopy: rule-out fistula in midesophageal lesions. ❚Routine Investigations: CBC, chemistries, LFTs. Cancer lower 1/3 Filling defect (ulcerative type)Rat tail appearance Apple core appearance
  10. 10. Figure: A proposed treatment algorithm for esophageal cancer.
  11. 11. Treatment
  12. 12. Management depends upon: ❚ Site of disease ❚ Extent of disease involvement ❚ Co-morbid conditions ❚ Patient preference.
  13. 13. Surgery ❚ Prerequisite for surgery ❙ disease should be 5 cm beyond cricophyrangeus. ❚ Surgery indications ❙ Lower 1/3 rd oesophageal ds involving GE junction. ❙ Tumor size <5 cm . ❙ palliative surgery ❚ 5-Year OS for surgery alone is 20–25% (no significant difference between surgical techniques according to results of 2 meta-analyses) ❚ Local failure rate around 19–57% when used alone ❚ surgical morbidity/mortality related to experience of the surgeons.
  14. 14. Types of Surgery ❚ Transhiatal esophagectomy: for tumors anywhere in esophagus or gastric cardia. No thoracotomy. Blunt dissection of the thoracic esophagus. Left with cervical anastomosis. Limitations are lack of exposure of midesophagus and direct visualization and dissection of the subcarinal LN cannot be performed. ❚ Right thoracotomy (Ivor-Lewis procedure): good for exposure of mid to upper esophageal lesions. Left with thoracic or cervical anastomosis. ❚ Left thoracotomy: appropriate for lower third of esophagus and gastric cardia. Left with low-to-midthoracic anastomosis. ❚ Radical (en block) resection: for tumor anywhere in esophagus or gastric cardia. Left with cervical or thoracic anastomosis. Benefit is more extensive lymphadenectomy and potentially better survival, but increased operative risk.
  15. 15. Chemotherapy ❚ No data proving that chemotherapy alone provides improved survival or palliation. Partial response, not long-term remission, is the rule ❚Indication ❙ Used in combination with radiation for locally advancedcancers ❙ Used as single treatment modality in stage IVdisease ❙ Combination chemotherapy has been used preoperatively in a combined modality approach to esophageal Ca in hopes of controlling occult metastatic disease and improving the resectability rate.
  16. 16. ❚ Platinum doublet is preferred over single agents ❚ Cisplatin plus 5-FU or docetaxel are commonly used combinations Regimens: ❚ Paclitaxel and carboplatin ❚ Cisplatin and 5-FU or capecitabine ❚ Oxaliplatin and 5-FU or capecitabine ❚ Paclitaxel or docetaxel and cisplatin ❚ Carboplatin and 5-FU ❚ Irinotecan and cisplatin ❚ Oxaliplatin, docetaxel and capecitabine ❚ Epirubicin, cisplatin and 5-FU (Only for adenocarcinoma)
  17. 17. Radiotherapy ❚Curative ❙Radical RT ❙Pre-Op RT ❙Post Op RT ❙Concurrent chemo-radiation ❚Palliative ❚EBRT ❚Brachytherapy
  18. 18. EBRT Techniques ❚ Patient Positioning: ❙ CERVICAL ESOPHAGUS: Supine with arms by the side ❙ MID AND LOWER THIRD: ❘ SUPINE With arms above their head if AP – PA portals are being planned ❘ PRONE if posterior obliques are beingincluded. • Esophagus is pulled anteriorly and spinal cord can be spared. ❚ ❚ IMMOBILISATION : ❙ Perspex cast ❙ Vertebral column should be as parallel to couch as possible. Barium swallow contrast to delineate the esophageal lumen and stomach.
  19. 19. EBRT – Cervical Esophagus Field Portals: ❚ AP – PA foll. by opposed oblique pair. ❚ 2 anterior obliques and 1 posterior field. ❚ 2 posterior obliques and 1 anterior field ❚ 4 field box with soft tissue compensators foll by obliques ( Univ of Florida tech ) ❚ SUPERIOR BORDER: At C 7 ❚ INFERIOR BORDER : At T 4 ( carina ) ❚ 2 cm lateral margins. ❚ SC nodes irradiated electively. ❚ SC nodes will be underdosed if oblique portals are used to treat primary; can be boosted by a separate field if required.
  20. 20. EBRT – Mid & Lower1/3rd  AP – PA followed by 1 Ant and 2 Post oblique pair  4 FIELD : AP-PA & opposed laterals – for mid 1/3rd lesions with patient in prone position.  AP-PA upto 43 Gy foll by 2 Post obliques upto 50 Gy ( gross disease boosted to 60 Gy ) ❚ SUPERIOR BORDER: 5 cm proximal to superior extent of disease. ❚ INFERIOR BORDER: ❙ MID 1/3RD – AT GE jn. As visualised by Barium swallow ❙ LOWER 1/3RD - Coeliac plexus ( L 1 ) to be included.
  21. 21. Radiotherapy for CA esophagus
  22. 22. EBRT - DOSES ❚ Energy ❙ 6 – 10 MV linac orCo60 ❚ Chemoradiation: ❙ 50.4 Gy in 28 # at 1.8 Gy per # ❙ Boost to 60 – 66 Gy for residual disease ❚ Radical RT: ❙ 45 Gy / 25 # / 1.8 Gy per # ❙ boost with 2 cm margin to total dose of 60Gy ❚ Dose limitations ❙ Spinal cord Dmax:45 Gy at 1.8 Gy/fx ❙ Lung: Limit 70% of both lungs <20 Gy ❙ Heart: Limit 50% of ventricles <25 Gy
  23. 23. Brachytherapy (Intraluminal) ❚ As a boost after EBRT or as a palliative measure ❚ Local control of 25% - 35 in palliative setting ❚ In curative setting, addition of brachytherapy does not improve results compared to Chemoradiation. ❚ Limit dose to critical structure ❚ Dose escalation to primary ❚ Relief bleeding, pain and improves swallowing status in palliative setting.
  24. 24. American Brachytherapy Society Guidelines Patient selection: ❙ Primary tumor length ≤ 10 cm length ❙ Tumor confined to esophagealwall ❙ Thoracic esophaguslocation ❙ No nodal / systemicmetastasis. Contraindications: ❙ T Efistula ❙ Cervical esophagouslocation ❙ Stenosis which cannot bebypassed
  25. 25. Contd… ❚ ❚ ❚ ❚ EBRT 45 – 50 Gy in 1.8-2.0Gy /#,5#/wk ❘ HDR – 5 Gy x two # one week apart , 2 – 3weeks after EBRT. ❘ LDR – single 20 Gy # @ 0.4 – 1.0 Gy per hr, 2 -3 weeks after EBRT. Never concurrently with chemotherapy Ext diameter of applicator must be 6 – 10 mm. Active length : visible tumor by UGI scopy plus 1 – 2 cm proximal & distal margin. ❚ Dose is prescribed 1 cm from mid source or mid dwell position.
  26. 26. APPLICATORS
  27. 27. Trials – RT alone ❚ No randomized trials of RT VsSx ❚ 5 yr survival with conventional RT : < 10% ❚ Tumors < 5 cm , 5 yr survival :20% ❚ Stage wise 5 yrsurvival: ❙ Stage I –20% ❙ Stage II –10% ❙ Stage III – 3% ❙ Stage IV –0%
  28. 28. Contd… ❚ For cervical esophagus, cure rates were similar with Radical RT or Sx alone. ❚ RT or Sx alone DOES NOT alter the natural history of the disease. ❚ RTOG 8501: RT Vs Chemo RT ❙ Better LRC and improved OS with ChemoRT  RT alone should be used for palliation or in medically unfit patients.
  29. 29. Trials– PreOP RT ❚Principle: ❙  resectability,  likelihood of tumor dissemination during Sx ,  radioresponsiveness due to unaltered blood supply ❙ 5 randomised trials ,shows no apparent clinical benefit to use of preop rt alone except, ❙ Only one trial ( Huang et al ) showed survival advantage of 46% Vs 25% with 40 Gy RT ❙ Recent meta analysis Oesophageal Cancer Collaborative Group study showed no clear survival advantage.  No difference in resectability rates, LRC or survival with pre-op RT
  30. 30. Trials– PostOP RT ❚Advantages: ❙ Treat areas at risk for recurrences while minimizing dose to OAR. ❙ Patients with node negative , completely resected T1 / T2 tumors can be excluded. stomach or bowel used for ❚ Disadvantage: ❙Tolerance of interpositioning.
  31. 31. Contd… • ❚ 2 randomised trials: • ❙ Peniere et al:- • ❘ 221 pts, mid / low 1/3rd growth • ❘ RT : 45- 55 Gy @ 1.8 Gy per # • ❘ 3 yrs -  local failure rate ( from 35% to 10%) • - no significant disease free survival. • ❙ Fok et al:- • ❘ 130 pts , RT – 49 Gy @ 3.5 Gy per # • ❘ Local failure rate  in patients who had palliative resection ( from 46% to 20% ) • ❘ No difference for completely resected patients •  Post op RT improves localcontrol, but does not confer any survival advantage.
  32. 32. ChemoRT followed Sx Vs.ChemoRT ❚ Patient undergoing surgery have worse quality of life. ❚ Surgery following combined CRT appears to improve local control, its impact on ultimate survival remains controversial.
  33. 33. Trials– Chemoradiation ChemoRT Vs RT Alone ❚ RTOG 8501 INTERGROUP TRIAL: ❙ 121 pts: 60 pts RT alone – 64 Gy @ 2 Gy per # 61 pts chemoRT – 50 Gy RT + 5 FU + CDDP – on 1 , 5 , 8 & 11 weeks ❙ Median survival : 8.9 Vs 12.5 months ❙ 5 yr survival : 0% Vs 30 % ❙ Distant mets @ 5 yrs: 40% Vs 12 % ❙ Acute toxicity : 25% Vs 44 % ❚  Median & overall survival, LRR and Acute toxicity in Chemo RT arm.  Chemoradiation is a standard Non-surgical Tx.
  34. 34. Contd… RT dose escalation in Chemo RT ❚ Intergroup 0123 TRIAL – 218 pts ❙ Chemoradiation - either 50.4 Gy or 64.8Gy ❙ No significant difference in median survival, 2 yr survival or loco- regional failure.  Intensification of RT dose beyond 50.4 Gy(in combination with chemotherapy ) does not improve results.
  35. 35. Contd… Sx ALONEPRE OP CHEMO RT Vs ❚ 44 Randomised trials ❚ 2 studies showed  in local recurrence ❙ Urba et al – 19 % Vs 42 % ❙ Bosset et al ( EORTC ) – 28% Vs 40% ❚ One study showed significant survival benefit at 3 yrs (in pts who had a pathologic CR ) ❙ Urba et al – 64% Vs 19% ❚ One study (Walsh et al) showed benefit in median (16 Vs 11 months ) and overall survival at 3 yrs ( 32 Vs 6%)  Results support TRIMODALITY approach.
  36. 36. Pre-operative Chemotherapy The role of preoperative chemotherapy alone is controversial, according to mixed results from clinical trials.
  37. 37. Stage Recommended treatment Stage I–III and IVA resectable medically-fit definitive chemo-RT (preferred for cervical esophagus) Or, Pre-op chemo-RT →surgery. Surgery preferred for adenocarcinoma regardless of response to chemo-RT. Or, surgery. (noncervical T1N0 and young T2N0 patients with primaries of lower esophagus or gastroesophageal junction. Indications for post-op chemo-RT include: unfavorable T2N0, T3/4, LN+, and/or close/+ margin. Stage I–III inoperable Definitive chemo-RT Stage IV palliative Concurrent chemo-RT (5-FU + cisplatin, 50 Gy) or RT alone (e.g., 2.5 Gy × 14 fx) or chemo alone or best supportive care. Pain: medications ± RT Bleeding: endoscopic therapy, surgery, or RT
  38. 38. Current approach ❚ EBRT using 3D-CRT to a total dose of 50.4 Gy (1.8 Gy per daily fraction) is standard. ❚ IMRT is often utilized to minimize exposure to adjacent structures. ❚ Proton beam in combination with chemotherapy is being explored. ❚ Targeted biologic agents added to standard cytotoxic chemotherapy is being explored
  39. 39. Conclusion ❚ Esophageal cancer is the 7th leading cause of cancer deaths. ❚ Adenocarcinoma now accounts for over 50% of esophageal cancer in the USA, due to association with GERD & obesity. ❚ Dysphagia and weight loss are the two most common presentations in patients with esophageal cancer. ❚ Endoscopic ultrasound (EUS) is necessary to accompany a complete workup for proper staging and diagnosis of esophageal cancer. ❚ Surgery is the standard of care for early-stage esophageal cancer. ❚ Preoperative chemotherapy and radiation is the standard option for locally advanced esophageal cancer in surgically eligible patients.
  40. 40. Thank You

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