Post-treatment management of esophageal cancers: Surgical considerations Stephen Swisher, MD PhD Robert F. Fly Professor of Surgical Oncology Chairman,

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Presentation transcript:

Post-treatment management of esophageal cancers: Surgical considerations Stephen Swisher, MD PhD Robert F. Fly Professor of Surgical Oncology Chairman, Department of Thoracic and Cardiovascular Surgery MD Anderson Cancer Center Houston, TX

Role of surgery for treatment of tumor recurrence after Role of surgery for treatment of tumor recurrence after Esophagectomy (without chemoXRT)Esophagectomy (without chemoXRT) surgical options for recurrent tumor after primary esophagectomy surgical options for recurrent tumor after primary esophagectomy Colon Jejunum

Role of surgery for treatment of tumor recurrence after Role of surgery for treatment of tumor recurrence after Esophagectomy (without chemoXRT)Esophagectomy (without chemoXRT) surgical options for recurrent tumor after primary esophagectomy surgical options for recurrent tumor after primary esophagectomy

Role of surgery for treatment of tumor recurrence after Role of surgery for treatment of tumor recurrence after Esophagectomy (without chemoXRT)Esophagectomy (without chemoXRT) surgical options for recurrent tumor after primary esophagectomy surgical options for recurrent tumor after primary esophagectomy

Role of surgery for treatment of tumor recurrence after Role of surgery for treatment of tumor recurrence after Esophagectomy (without chemoXRT)Esophagectomy (without chemoXRT) surgical options for recurrent tumor after primary esophagectomy surgical options for recurrent tumor after primary esophagectomy

Role of surgery for treatment of tumor recurrence after Role of surgery for treatment of tumor recurrence after Esophagectomy (without chemoXRT)Esophagectomy (without chemoXRT) surgical options for recurrent tumor after primary esophagectomy surgical options for recurrent tumor after primary esophagectomy

Role of surgery for treatment of tumor recurrence after Role of surgery for treatment of tumor recurrence after Definitive chemoradiationDefinitive chemoradiation Is surgery possible after chemoradiation Is surgery possible after chemoradiation What are potential risks and benefits What are potential risks and benefits

Role of surgery for treatment of tumor recurrence after Role of surgery for treatment of tumor recurrence after Definitive chemoradiationDefinitive chemoradiation Is surgery possible after chemoradiation Is surgery possible after chemoradiation What are potential risks and benefits What are potential risks and benefits

Role of surgery for treatment of tumor recurrence after Role of surgery for treatment of tumor recurrence after Pre-op chemo-XRT- in patients who recur after an complete clinical response.Pre-op chemo-XRT- in patients who recur after an complete clinical response.

Role of surgery for treatment of tumor recurrence after Role of surgery for treatment of tumor recurrence after Pre-op chemo-XRT- in patients who recur after an complete clinical response.Pre-op chemo-XRT- in patients who recur after an complete clinical response.

Role of surgery for treatment of tumor recurrence after Role of surgery for treatment of tumor recurrence after Pre-op chemo-XRT- in patients who recur after an complete clinical response.Pre-op chemo-XRT- in patients who recur after an complete clinical response.

Role of surgery for treatment of tumor recurrence after chemoradiation Role of surgery for treatment of tumor recurrence after chemoradiation Salvage esophagectomySalvage esophagectomy What is it; Who are potential candidates; Survival benefit What is it; Who are potential candidates; Survival benefit

Role of surgery for treatment of tumor recurrence after chemoradiation Role of surgery for treatment of tumor recurrence after chemoradiation Salvage esophagectomySalvage esophagectomy What is it; Who are potential candidates; Survival benefit What is it; Who are potential candidates; Survival benefit

Role of surgery for treatment of tumor recurrence after chemoradiation Role of surgery for treatment of tumor recurrence after chemoradiation Salvage esophagectomySalvage esophagectomy What is it; Who are potential candidates; Survival benefit What is it; Who are potential candidates; Survival benefit

Role of surgery for treatment of tumor recurrence after chemoradiation Role of surgery for treatment of tumor recurrence after chemoradiation Salvage esophagectomySalvage esophagectomy What is it; Who are potential candidates; Survival benefit What is it; Who are potential candidates; Survival benefit RTOG 0246

Role of surgery for treatment of tumor recurrence after chemoradiation Role of surgery for treatment of tumor recurrence after chemoradiation Salvage esophagectomySalvage esophagectomy What is it; Who are potential candidates; Survival benefit What is it; Who are potential candidates; Survival benefit

Role of surgery for treatment of tumor recurrence after chemoradiation Role of surgery for treatment of tumor recurrence after chemoradiation Salvage esophagectomySalvage esophagectomy What is it; Who are potential candidates; Survival benefit What is it; Who are potential candidates; Survival benefit RTOG 0246

Q1

Repeat endoscopy 1 year after surgery to rule out residual Barrett’s or dysplasiaRepeat endoscopy 1 year after surgery to rule out residual Barrett’s or dysplasia No CT Scan, CXR or PET scan unless symptoms because of low likelihood of distant mets with T1N0, LVI negativeNo CT Scan, CXR or PET scan unless symptoms because of low likelihood of distant mets with T1N0, LVI negative

Repeat endoscopy 1 year after surgery to rule out residual Barrett’s or dysplasiaRepeat endoscopy 1 year after surgery to rule out residual Barrett’s or dysplasia No CT Scan, CXR or PET scan unless symptoms because of low likelihood of distant mets with T1N0, LVI negativeNo CT Scan, CXR or PET scan unless symptoms because of low likelihood of distant mets with T1N0, LVI negative

Q2

Path CR – no diff. in relapse locations Path CR – no diff. in relapse locations What we do: if no sxs - CT scan +/- EGD q6 mos x 4 then yrly (only asx group to help – LN, ? Anast Rec) What we do: if no sxs - CT scan +/- EGD q6 mos x 4 then yrly (only asx group to help – LN, ? Anast Rec)

Q3

Salvage Esophagectomy Salvage Esophagectomy no metastatic disease,no metastatic disease, regional LNregional LN no other curative Rxno other curative Rx

Q4

Since unable to tolerate surgery Since unable to tolerate surgery few therapeutic options if Asymtomatic –few therapeutic options if Asymtomatic – PE q 6 monthsPE q 6 months If symptomatic If symptomatic studies to assess for palliative Rx –Stents, EMR, PDT, Brachytherapystudies to assess for palliative Rx –Stents, EMR, PDT, Brachytherapy

State of the Art

Summary of today’s state of the art Summary of today’s state of the art Asymptomatic recurrences that can be helped : Asymptomatic 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 conduit Salvage Surgery: Colonic/Jejunal conduit CRT CRT Local/Distant LNLocal/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 years? the next 10 years? What new modalities are on the horizon in the next 5 years? the next 10 years? Novel Molecular Therapeutics Novel Molecular Therapeutics PET Scan identification of non-responders to allow additional treatment prior to resection PET Scan identification of non-responders to allow additional treatment prior to resection