Esophageal and GEJ Cancers. Case Presentations

Transcription

1 Esophageal and GEJ Cancers Case Presentations

2 Locally Advanced GEJ Cancer (Case 1) A 55 year old man with longstanding GERD presents with increasing solid food dysphagia. EGD reveals a 3 cm mass in the GE junction 40 cm from the incisors, and a biopsy reveals adenocarcinoma, Siewert II. A CT scan of the chest and abdomen reveals a GE junction mass and no metastases. EUS reveals a T3N1 lesion, FNA of a periesophageal node is +. PET reveals a PET avid mass with no metastatic disease.

3 Locally Advanced T3N1 GEJ Cancer HER2 testing is negative. Your choice of therapy is (Case 1) 1) Preop ECX x 4 then surgery. 2) Preop CF x 2 then surgery. 3) Preop paclitaxel, carboplatin, RT then surgery. 4) Surgery first then post op 5-FU/LV and RT. 5) Induction chemotherapy with FOLFOX followed by 5-FU, Oxaliplatin, RT and surgery. 6) Induction chemo with FOLFOX with a repeat PET scan, change chemotherapy during RT if no PET response.

4 Locally Advanced T3N1 GEJ Cancer (Case 1) HER2 testing is 3+. Your choice of therapy is 1) Trastuzumab, paclitaxel, carboplatin RT then by surgery followed by 1 year of trastuzumab. 2) Preop FLOT + Trastuzumab then surgery followed FLOT, Trastuzumab and 1 year of Trastuzumab. 3) Periop FLOT + Trastuzumab + Pertuzumab. 4) Preop FLOT alone. 5) Preop paclitaxel, carboplatin, RT and surgery.

5 Locally Advanced T3N1GEJ Cancer(Case 1) The patient is HER2 negative. He receives preop paclitaxel, carboplatin, RT and undergoes Ivor Lewis esophagectomy. Pathology reveals a 50% treatment effect with residual T3 disease and 2 of 20 nodes are positive for metastatic disease.

6 Locally Advanced T3N1 GEJ Cancer (Case 1) Your choice of therapy is: 1) Observation. 2) Postoperative ECX. 3) Postoperative FOLFOX. 4) Postoperative FLOT. 5) Entrance onto a clinical trial comparing observation vs 1 year of regorafenib.

7 Metastatic GEJ Cancer (Case 2) The patient is observed. 18 months after surgery he presents with RUQ pain. A CT scan reveals bilobar hepatic metastases, biopsy + for metastatic adenocarcinoma. ECOG PS is 1. Liver biopsy results are pending.

8 Metastatic GEJ Cancer (Case 2) Your next step is 1) Genomic sequencing looking for a targetable mutation. 2) Treatment with FOLFOX or CAPEOX. 3) Treatment with EOX. 4) Treatment with FLOT. 5) Treatment with FOLFIRI.

9 Metastatic GEJ Cancer (Case 2) Repeat HER2 testing is 3+ on the liver biopsy. ECOG PS 1, labs normal except for ALK PHOS of 245.

10 Metastatic GE Junction Cancer (Case 2) Your initial choice of therapy is: 1) Capecitabine, cisplatin + trastuzumab 2) Capecitabine, cisplatin + trastuzumab and pertuzumab 3) FOLFOX + trastuzumab 4) FOLFOX + lapatinib 5) FOLFIRI + trastuzumab 6) Other.

11 Metastatic GE Junction Cancer (Case 2) The patient commences FOLFOX + trastuzumab. His pain resolves. He develops mucositis after 3 cycles requiring dose reductions in 5-FU. CT scans at 4 and 8 cycles show a substantial response. After cycle 10 oxaliplatin is stopped for grade 2 neuropathy (cumulative dose 745 mg/m2)

12 Metastatic GE Junction Cancer (Case 2) He continues on 5-FU + Trastuzumab and a CT at 6 and 8 months shows ongoing response which plateaus. His neuropathy is grade 1. Your choice of therapy at this time is 1) Continue 5-FU + Trastuzumab. 2) Continue trastuzumab alone. 3) Stop therapy and observe. 4) Reintroduce oxaliplatin to 5-FU/Trastuzumab. 5) Other.

13 Metastatic GE Junction Cancer (Case 2) 5-FU and trastuzumab are continued. CT scans show maintained response until 15 months. He is hoarse, losing weight, and a scan indicates increasing liver metastases and mediastinal nodes. Genomic profiling reveals ERBB2 amplification, FLT3 mutation (activating downstream activation of AKT/RAS/mTOR), amplification of CRKL (sensitivity to sarc/bcr-abl kinase inhibition), p53 mutation, loss of SMAD4 and RUNX1

14 Metastatic GE Junction Cancer (Case 2) Your next choice of therapy is 1) Reintroduce cisplatin or oxaliplatin to 5-FU + Trastuzumab. 2) Paclitaxel + ramucirumab. 3) Paclitaxel + trastuzumab. 4) FOLFIRI + / - ramucirumab. 5) TDM-1 6) Regorafenib or sorafenib (targets FLT3) 7) Other.

15 Metastatic GE Junction Cancer (Case 2) The patient progresses on paclitaxel + ramucirumab. He maintains PS ECOG 1. Your next choice in therapy is 1) FOLFIRI 2) Irinotecan monotherapy 3) TDM-1 4) Referral for phase I trial. 5) Best supportive care. 6) Other.