ESOPHAGEAL CANCER. Dr. Paul Gardiner December 17, 2002 Discipline of Surgery Rounds

Size: px

Start display at page:

Download "ESOPHAGEAL CANCER. Dr. Paul Gardiner December 17, 2002 Discipline of Surgery Rounds"

Dayna McKinney
6 years ago
Views:

1 ESOPHAGEAL CANCER Dr. Paul Gardiner December 17, 2002 Discipline of Surgery Rounds

2 ESOPHAGEAL CANCER I. EPIDEMIOLOGY INCIDENCE, DIAGNOSIS & STAGING II. TREATMENT OPTIONS Current role of induction therapies and surgery versus surgery alone Surgical approaches III. METHODS OF PALLIATION

3 ESOPHAGEAL CANCER I Two (2) histologic subtypes squamous cell carcinoma and adenocarcinoma. Incidence of adenocarcinoma distal esophagus increasing dramatically in US & Europe. Primary risk factor is chronic heartburn leading to sequence of esophagitis Barrett's esophagus and ultimately adenocarcinoma. Overall 5 year survival rate remains a disappointing 5-10 %.

4 ESOPHAGEAL CANCER Esophageal carcinoma is a lethal malignancy with an increasing incidence and a shift in histologic type from squamous carcinoma to adenocarcinoma. 30 % patients present with disseminated disease (STAGE IV) 50% STAGE II-III III disease and are at high risk for systemic treatment failure and death despite adequate local therapy (surgery or chemoradiation) 20 % patients present with Stage 0 and Stage I disease.

5 ESOPHAGEAL CANCER Esophageal resection is the "gold standard " for esophageal cancer. Majority of patients are unable to undergo surgery however because of extent of disease or co- morbidities. Stage I - 5 year survival 80% Stage II - III (locally advanced) - 5 year survivals with complete resection 30-35%. (Poor long term success)

6 STAGING OF ESOPHAGEAL CANCER Clinical Examination Lab Work Chest X-RayX Barium Swallow Endoscopy / Biopsy CT

7 STAGING OF ESOPHAGEAL CANCER EUS PET CT - PET MR Laparoscopy Thorascopy Molecular Biology

8 CT Staging of Esophageal Carcinoma Determination of T status Determination of N status and non-regional LN status Determination of non-nodal nodal MIB status

9 EUS Staging of Esophageal Carcinoma Determination of T status Determination of N status and non-regional LN status Determination of non-nodal nodal MIB status

10 PET STAGING OF ESOPHAGEAL CARCINOMA

11 TREATMENT ASPECTS II OF ESOPHAGEAL CANCER The decade of the 1990's saw the unprecedented introduction of new cancer chemotherapeutic agents. These drugs many with unique mechanisms of action and expanded spectra of activity have improved the treatment options for many of the solid tumors such as lung, breast, colorectal, pancreatic and esophageal cancers.

12 INDUCTION RADIOTHERAPY INDUCTION CHEMOTHERAPY INDUCTION CHEMORADIOTHERAPY SURGERY

13 INDUCTION CHEMORADIOTHERAPY

14 Table 1. Nonrandomized trials of induction chemoradiotherapy and surgery Author Year Patients Chemo Rad CR (P) Mort Years of Survival Lackey C/F (2 y) Forastiere C/F/V (5 y) Naunheim C/F (3 y) Bates C/F (3 y) Jones C/F (3 y) Suntharalingham C/F (3 y) Chidel C/F (3 y)

15 INDUCTION CHEMORADIOTHERAPY

16 Table 2. Randomized trials of induction chemoradiotherapy and surgery Author Year Patients Chemo Rad CR (P) Mort Years of Survival Nygaard C/B (3 y) Le Prise C/F (3 y) Walsh C/F (3 y) Bosset C (3 y)

17 FUTURE TRIALS May involve biochemical markers which may be predictive of chemotherapy response and resistance Thymidylate synthase P 53 and P 21 American College of Surgeons Oncology Group (ACOSOG) Trial Z0060 to determine utility of PET scanning in staging of patients with potentially operable carcinoma of esophagus.

18 Rationale for Neoadjuvant Therapy Improves local control Enhances resectability by downsizing Allows assessment of response of first degree tumor Treats potential micrometastases

19 INDUCTION CHEMORADIOTHERAPY Current Ongoing Trials RTOG (Planned 298 patients) High Dose v.s.. conventional XRT Concomitant Cisplatinum/5FV

20 CALGB CALGB 9781 (Planned 495 patients) Surgically resectable SCC/Adenocarcinoma Esophagus/ / or/eg Junction Neoadjuvant Cisplatinum/ / 5 FV and Concomitant Radiation and Surgery versus surgery alone.

21 FAQ'S Are further clinical trials essential to determine the role of chemotherapy, radiation and surgery...? Enthusiasm in the surgical community? Whether or not pathologic complete response patients still need surgery...? PET, Laparoscopy and Thoracoscopy and their roles in staging.? Other questions..?

22 TREATMENT OPTIONS FOR ESOPHAGEAL CANCER 1. Esophagectomy 2. Chemotherapy / Planned OR 3. Radiotherapy / Planned OR 4. Chemo-Radiation / Planned OR 5. Chemo-Radiation Only 6. Radiation Only

31 SURGICAL APPROACHES 1. Trans-hiatal Esophagectomy 2. Abdominal Right-Thoracic Esophagectomy (Ivor Lewis) 3. Left Thoraco-Abdominal Esophagectomy 4. Combined Abdomino-Thoraco Thoraco-Cervical Esophagectomy 5. Trans-abdominal abdominal Esophagogastrectomy 6. En Bloc Resection for Esophageal Cancer 7. Endo-Esophageal Esophageal Pull-through Operation

32 COMPLICATIONS OF SURGERY FOR ESOPHAGEAL CANCER

33 Methods of Palliation to Relieve Dysphagia, Aspiration & Pain III 1. Palliative Resection 2. Esophageal Bypass 3. Esophageal Dilation 4. Esophageal Intubation 5. Laser Procedures 6. Tracheo-Esophageal Fistula * * * 7. Feeding Gastrostomy and Jejunostomy END

WHO BENEFITS FROM ADJUVANT CHEMOTHERAPY RADIATION CHEMORADIATION? Dr. Paul Gardiner April 23, 2001 Discipline of Surgery Grand Rounds

WHO BENEFITS FROM ADJUVANT CHEMOTHERAPY RADIATION CHEMORADIATION? Dr. Paul Gardiner April 23, 2001 Discipline of Surgery Grand Rounds LUNG Dr. Greenland ESOPHAGUS Dr. Gardiner ESOPHAGEAL CANCER 1200 new