Esophageal and GEJ Cancers Case Presentations
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.
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.
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.
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.
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.
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.
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.
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.
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.
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)
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.
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
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.
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.