Transcript Esophageal Cancer , New updates in Chemoradiation

Esophageal Cancer , New updates
in Chemoradiation
Dr Hamid Reza Dehghan Manshadi
Radiation Oncologist
Iran University of Medical sciences
• Primary tumor(T)
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Staging
Tis : Carcinoma in situ (Severe dysplasia)
T1: Lamina Properia or submucosa
T2 :Muscularis properia
T3 : Invades Advantitia
T4: Invades Adjacent structures (T4a : resectable
T4b : unresectable)
• Regional Lymph Nodes (N) :
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regional LN Mts N0 , N1 (No. of LNs? )
• Distant Metastasis(M) : M0 ,
M1
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Lower Thoracic :
M1a : Celiac LNs
M1b
: Other Distant Mts
Mid Thoracic : M1a : not Applicabale
M1b : nonregional LNs and / or other distant Mts
Upper Thoracic ; M1a : Cervical LNs
M1b : other distant Mts
• Point : GEJ tumors included in esophageal
Tumor Staging
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STAGE 1 ; T1N0M0
Stage IIA : T2/T3N0 M0
Stage IIB :T1/T2 N1 M0
Stage III : T3N1M0/
T4anyNM0
• Stage IVA :anyT anyN
M1a
• Stage IVB : anyT anyN
M1b
Evaluations for Staging
• Barium swallow
• CT Scanning:nodal staging 29%-42%, poor for T
staging
• EUS : 89% for T, 75% for N
• EUS / FNA : 89% for T , 87% for N
• PET/ CT: more accurate for Mts. 20% unnecessary
surgery reduction
• Laparoscopy and Thoracoscopy
• Bronchoscopy
SQUAMOUS CELL VERSUS ADENOCARCINOM
• Incidence :16,470 diagnosis, 14,530 deaths
• SCCs tend to arise 10 years earlier
• The pattern of first recurrence after resection:
• locoregional vs distant Mts
• Better Survival in Adenocarcinoma?
• Conclusion :
• The treatment plan and OS are the same
localized cancers of the esophagus and
esophagogastric junction
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SURGERY ALONE only 30 to 40 percent of patients have potentially
resectable disease at presentation, five-year survival rates of 15 to 20 percent
for surgery alone
RT ALONE : 60 to 66 Gy over a period of 6 to 6.6 weeks
survival rates
of 5 to 20 percent
With 3D planning techniques and 69 Gy dose
3 & 5 years survival was
the same as surgery alone ((61 and 37 percent)(SCC only)
CHEMORADIOTHERAPY :
RTOG 85-01 : comparing RT alone(64 Gy) vs Chemoradiation (Cis 75mg/m2 +
5fu infusional1000mg/m2 d1 d4,week 1&5 + 50 Gy RT) result was
excellent for Chemoradiation group
Intergroup 0123:comparing 50.4 Gy RT + chemo with 64 Gy RT + Chemo
No better results with higher tumor doses
Preoperative chemoradiotherapy
Irish sutdy :Chemoradiation vs surgery alone, improved median (16 versus 11
months) and three-year survival (32 versus 6 percent)
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Michigan study:100 pts,locoregional spread (SCC, Adeno),
randomized for surgery alone or induction chemoradiation
(cis/5fu/vbl)
better locoregional control, better 3 years
survival
• 3 other study compared sequential chemotherapy+RT +
surgery vs surgery alone showed no significant improvement
• Induction chemotherapy and concurrent
chemoradiotherapy :
• Swedish trial :12-16 weeks chemotherapy chemoradiation
+surgery , result: no significant survival imrovement
• NEOADJUVANT CHEMOTHERAPY:
• 8 trials meta-analysis revealed no significant improvement in 2 years
survival in SCC but significant benefit with Adenocarcinoma(UK MRC
trial)
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INDUCTION CHEMORADIOTHERAPY VERSUS CHEMOTHERAPY
The multicenter German POET: comparing induction chemotherapy to
chemoradiation in GE Adenocarcinomas patients undergoing chemoradiotherapy
had better median (33 versus 21 months) and three-year survival (47 versus 28
percent, p = 0.07)
CERVICAL ESOPHAGUS TUMORS
SUMMARY AND RECOMMENDATIONS:
After chemoradiation , inclusion of surgery is preferred for clinically resectable
esophageal cancer regardless of histology
concurrent trimodality approach (concomitant chemoradiotherapy followed by
surgery) provides a survival benefit compared to surgery alone
local control appears to be better with preoperative chemoradiotherapy compared to
surgery alone
• It is suggest combined modality therapy using preoperative
chemoradiotherapy followed by surgery rather than either surgery
alone or definitive chemoradiotherapy for patients with stages IIA,
IIB, and III esophageal SCC or adenocarcinoma of the distal
esophagus or EGJ
Chemoradiation regimens
• Infusional 5-FU 1000 mg/m2 per day for 96 hours during weeks
1 and 5 of external beam radiation therapy (EBRT)
Cisplatin 75 mg/m2, on day 1, during weeks 1 and 5 of EBRT
EBRT (50.4 Gy in daily 1.8 Gy fractions, given concurrently with
cycles 1 and 2 of chemotherapy
.Post-chemoradiotherapy surgery
.Salvage esophagectomy
.BRACHYTHERAPY
.Endoscopic interventions
(dilation, placement of an endoluminal stent, laser, and
photodynamic therapy)
• Chemotherapy for Advanced Disease:
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DCF (Docetaxel, Cisplatin, 5FU),Esp. In GEJ
Irinotecan + Cisplatin ,Esp, In SCC of esophagus
ECF (Epirubicin, Cisplatin, 5FU)
Capecitabin ,Oxaliplatin (as effective as Cis/5FU)
• Targeted Therapy:
• ToGA Study :Multicenter,phase III study : Cis/5FU + Trastuzomab
(HER-2 + ,GE & Gastric Cancer) =Higher Median OS (13.5 months
vs 11.1 months ) without significant higher toxicity
• Cetuximab
• Erlotinib
• Bevacizumab