Post-treatment management of Post-treatment management of esophageal cancers:esophageal cancers:
Surgical considerationsSurgical considerations
Stephen Swisher, MD PhDStephen Swisher, MD PhDRobert F. Fly Professor of Surgical OncologyRobert F. Fly Professor of Surgical Oncology
Chairman, Department of Thoracic and Cardiovascular SurgeryChairman, Department of Thoracic and Cardiovascular SurgeryMD Anderson Cancer CenterMD Anderson Cancer Center
Houston, TXHouston, TX
Role of surgery for treatment of tumor recurrence afterRole of surgery for treatment of tumor recurrence after• Esophagectomy (without chemoXRT)Esophagectomy (without chemoXRT)
surgical options for recurrent tumor after primary esophagectomysurgical options for recurrent tumor after primary esophagectomy
Colon
Jejunum
Role of surgery for treatment of tumor recurrence afterRole of surgery for treatment of tumor recurrence after• Esophagectomy (without chemoXRT)Esophagectomy (without chemoXRT)
surgical options for recurrent tumor after primary surgical options for recurrent tumor after primary esophagectomyesophagectomy
Role of surgery for treatment of tumor recurrence afterRole of surgery for treatment of tumor recurrence after• Esophagectomy (without chemoXRT)Esophagectomy (without chemoXRT)
surgical options for recurrent tumor after primary esophagectomysurgical options for recurrent tumor after primary esophagectomy
Role of surgery for treatment of tumor recurrence afterRole of surgery for treatment of tumor recurrence after• Esophagectomy (without chemoXRT)Esophagectomy (without chemoXRT)
surgical options for recurrent tumor after primary esophagectomysurgical options for recurrent tumor after primary esophagectomy
Role of surgery for treatment of tumor recurrence afterRole of surgery for treatment of tumor recurrence after• Esophagectomy (without chemoXRT)Esophagectomy (without chemoXRT)
surgical options for recurrent tumor after primary surgical options for recurrent tumor after primary esophagectomyesophagectomy
Role of surgery for treatment of tumor recurrence afterRole of surgery for treatment of tumor recurrence after• Definitive chemoradiationDefinitive chemoradiation
Is surgery possible after chemoradiationIs surgery possible after chemoradiation What are potential risks and benefitsWhat are potential risks and benefits
Role of surgery for treatment of tumor recurrence afterRole of surgery for treatment of tumor recurrence after• Definitive chemoradiationDefinitive chemoradiation
Is surgery possible after chemoradiationIs surgery possible after chemoradiation What are potential risks and benefitsWhat are potential risks and benefits
Role of surgery for treatment of tumor recurrence afterRole of surgery for treatment of tumor recurrence after• Pre-op chemo-XRT- in patients who recur after an Pre-op chemo-XRT- in patients who recur after an
complete clinical response.complete clinical response.
Role of surgery for treatment of tumor recurrence afterRole of surgery for treatment of tumor recurrence after• Pre-op chemo-XRT- in patients who recur after an Pre-op chemo-XRT- in patients who recur after an
complete clinical response.complete clinical response.
Role of surgery for treatment of tumor recurrence afterRole of surgery for treatment of tumor recurrence after• Pre-op chemo-XRT- in patients who recur after an Pre-op chemo-XRT- in patients who recur after an
complete clinical response.complete clinical response.
Role of surgery for treatment of tumor recurrence after Role of surgery for treatment of tumor recurrence after chemoradiationchemoradiation• Salvage esophagectomy Salvage esophagectomy
What is it; Who are potential candidates; Survival benefitWhat is it; Who are potential candidates; Survival benefit
Role of surgery for treatment of tumor recurrence after Role of surgery for treatment of tumor recurrence after chemoradiationchemoradiation• Salvage esophagectomy Salvage esophagectomy
What is it; Who are potential candidates; Survival benefitWhat is it; Who are potential candidates; Survival benefit
Role of surgery for treatment of tumor recurrence after Role of surgery for treatment of tumor recurrence after chemoradiationchemoradiation• Salvage esophagectomy Salvage esophagectomy
What is it; Who are potential candidates; Survival benefitWhat is it; Who are potential candidates; Survival benefit
Role of surgery for treatment of tumor recurrence after Role of surgery for treatment of tumor recurrence after chemoradiationchemoradiation• Salvage esophagectomy Salvage esophagectomy
What is it; Who are potential candidates; Survival benefitWhat is it; Who are potential candidates; Survival benefit
RTOG 0246RTOG 0246
Role of surgery for treatment of tumor recurrence after Role of surgery for treatment of tumor recurrence after chemoradiationchemoradiation• Salvage esophagectomy Salvage esophagectomy
What is it; Who are potential candidates; Survival benefitWhat is it; Who are potential candidates; Survival benefit
Role of surgery for treatment of tumor recurrence after Role of surgery for treatment of tumor recurrence after chemoradiationchemoradiation• Salvage esophagectomy Salvage esophagectomy
What is it; Who are potential candidates; Survival benefitWhat is it; Who are potential candidates; Survival benefit
RTOG 0246RTOG 0246
Q1Q1
• Repeat endoscopy 1 year after surgery to rule out Repeat endoscopy 1 year after surgery to rule out residual Barrett’s or dysplasiaresidual Barrett’s or dysplasia
• No CT Scan, CXR or PET scan No CT Scan, CXR or PET scan unless symptoms unless symptoms because because of low likelihood of distant mets with T1N0, LVI negativeof low likelihood of distant mets with T1N0, LVI negative
• Repeat endoscopy 1 year after surgery to rule out Repeat endoscopy 1 year after surgery to rule out residual Barrett’s or dysplasiaresidual Barrett’s or dysplasia
• No CT Scan, CXR or PET scan No CT Scan, CXR or PET scan unless symptoms unless symptoms because because of low likelihood of distant mets with T1N0, LVI negativeof low likelihood of distant mets with T1N0, LVI negative
Q2Q2
Path CR – no diff. in relapse locationsPath CR – no diff. in relapse locations
What we do: if What we do: if no sxs no sxs - CT scan +/- EGD q6 mos x 4 then - CT scan +/- EGD q6 mos x 4 then yrly (only yrly (only asxasx group to help – LN, ? Anast Rec) group to help – LN, ? Anast Rec)
Q3Q3
Salvage Esophagectomy Salvage Esophagectomy • no metastatic disease, no metastatic disease, • regional LN regional LN • no other curative Rxno other curative Rx
Q4Q4
Since unable to tolerate surgery Since unable to tolerate surgery • few therapeutic options if few therapeutic options if AsymtomaticAsymtomatic – – • PE q 6 monthsPE q 6 months
If If symptomaticsymptomatic • studies to assess for palliative Rx –Stents, EMR, PDT, studies to assess for palliative Rx –Stents, EMR, PDT,
BrachytherapyBrachytherapy
State of the ArtState of the Art
Summary of today’s state of the artSummary of today’s state of the art
AsymptomaticAsymptomatic recurrences that can be helped : recurrences that can be helped : • CT Scans +/- Endoscopy q 6 mos x 4 then q yearCT Scans +/- Endoscopy q 6 mos x 4 then q year
• Anastomotic RecurrenceAnastomotic Recurrence Salvage Surgery: Colonic/Jejunal conduitSalvage Surgery: Colonic/Jejunal conduit CRTCRT
• Local/Distant LN Local/Distant LN Surgery or CRT (non-radiated area)Surgery or CRT (non-radiated area)
What new modalities are on the horizon in the next 5 What new modalities are on the horizon in the next 5 years? the next 10 years?years? the next 10 years?
Novel Molecular TherapeuticsNovel Molecular Therapeutics PET Scan identification of non-responders to allow PET Scan identification of non-responders to allow
additional treatment prior to resectionadditional treatment prior to resection