Moderators: David Cort, MD Alex Denes, MD Panelists: Stephen Swisher, MD, PhD Edward Lin, MD

Tumor staging T1- confined to mucosa/submucosa T2- extends to muscularis propria T3- extends into surrounding tissue T4 - involves major vessels, pleura, pericardium Nodal staging N0 - no nodes involved N1 - local nodes involved N2 - distant nodes involved

 Esophagectomy  Combined modality  Pre-operative chemo-radiation >>> esophagectomy  Esophagectomy >>>> Post-operative chemo-radiation  Non surgical  Definitive chemoradiation

Surgical marginsPathology margins  R0No tumorNo tumor  R1No tumor Microscopic tumor present  R2Tumor presentMacroscopic tumor present

 What are the usual sites of recurrence  Local  distant  Benefits  Palliative chemo ± radiation ▪ survival benefit ▪ Quality of life  Treatment of recurrence in lymph node outside the initial field of initial radiotherapy  How-  Physical Exam- what signs to look for  CT chest/abdomen- what findings to look for  EGD – what symptoms should prompt it  Serum CEA levels- ? In which patients  EUS - ? role  How often  Suggested protocols for follow up

 A 52 year old accountant with known history of Barrett’s esophagus and symptomatic reflux  surveillance endoscopy.  5 cm segment of Barrett’s esophagus proximal to the GE junction. ▪ Biopsy - Multiple foci of HGD  1.5 cm sessile polypoid lesion at the GEJ ▪ Biopsy- Invasive adenocarcinoma.

 T1- confined to the mucosa and submucosa and sparing the muscularis propria.  N0 – no enlarged lymph nodes

 PET/CT:  No nodal or distant metastases  He undergoes esophagectomy without complications  (R0 resection)  Surg path:  T1, N0, (M0) moderately differentiated adenocarcinoma,  No lympho-vascular infiltration  multiple foci of Barrett’s  all margins clear of tumor

1. CT chest and abdomen every 3 months 2. CT chest and abdomen every 6 months 3. CXR every 3 months 4. EGD every 3 months 5. All of the above 6. None of the above AQ1. Appropriate post treatment follow-up of this patient would involve

 What are the chances of tumor recurrence  What are the usual sites of recurrence  Local ▪ Treatment options ▪ Benefits  Distant ▪ Treatment options ▪ Benefits  Suggested follow up after treatment

T1N0 GEJ  The cure rate 80-90%.  If EMR or radiation cure rate 60-70% (then regular EGD is indicated).  Q 6 months for the first 2 years, then annual physical exams with routine blood work.  Imaging only when clinically indicated.

 Repeat 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 negative

 Repeat 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 negative

 A 65 year old house-wife with history of GERD presents with progressive dysphagia  EGD:  An irregular, non obstructing, ulcerated mass in the distal esophagus.  Biopsy: Moderately differentiated adenocarcinoma  EUS:  T3 tumor (infiltrating muscularis propria)  No enlarged lymph nodes  PET/CT:  intense FDG uptake in the distal esophageal mass  no lymph node or distant metastases

 Planned treatment:  Pre-operative chemoradiation followed by surgery  Patient recieves  combined modality therapy with radiation and chemotherapy  Follow up EGD: ▪ no residual mass and biopsy shows only radiation effect. Patient is now reluctant about proceeding with esophagectomy

1. Convince the patient to proceed with surgery as originally planned 2. Give additional chemo-radiation to full dose 3. Can wait and see how the patient performs 4. None of the above

 RTOG-Hersovic: Chemo-RT > RT: 5-year 32%, vs 12% 20% vs 0% 10 year survival. LR > 45%  Intergroup 0123: 50.4 Gy > 64.8 Gy  Phase III: Modern RT = S  CMT vs S: OR Three Meta-analysis (Ref 1-3). (Many small studies isolated positive study mostly with 5FU/Cisplatin/50.4 cGy. Urschel Am J Surgery 2003:6: Surgery 2005; 137: Gut 2004;7: Walsh et la. NEJM.1997 Kelsen DP NEJM 1998; Yu ASCO 2006 Abst 4012

 Chances of tumor recurrence  Sites of tumor recurrence  Local  distant  Treatment options  Salvage esophagectomy  Suggested follow up

 CT or CT/PET and endoscopy with biopsies q 3 months x2 then 6month x 3 then yearly (RTOG 0246)  Early follow/up similar survival to trimodality

 Esophagectomy  R0 resection  Path: ▪ No residual carcinoma in the esophagus ▪ 12 lymph nodes are clear

 What are the chances of tumor recurrence  What are the usual sites of recurrence  Local ▪ Treatment options ▪ Benefits  Distant ▪ Treatment options ▪ Benefits  Suggested follow up after treatment

 A 48 year old high school teacher presents with progressive dysphagia and weight loss  EGD:  large ulcerated nearly circuferential mass in the lower third of the esophagus.  Biopsy: Moderate to poorly differentiated adenocarcinoma with lymphovascular infiltration.  PET/CT:  Intense FDG uptake in paraesophageal lymph nodes.  No distant metastases.  EUS:  T3 tumor (Nearly circumferential mass, extension into the adventitia)  N1 (multiple enlarged regional lymph nodes)

T3N1 tumor

 Treatment:  combined modality therapy with radiation and chemotherapy.  Follow up EGD  75% regression of the mass.  Biopsy: residual adenocarcinoma.  Esophagectomy  R0 resection  Path: ▪ Residual moderately differentiated adenocarcinoma, ▪ foci of carcinoma in 3 regional lymph nodes.

1. Follow up with EGD and CT scan every 3 months 2. Follow up with EGD and CT scan every 6 months 3. Additional radiation therapy to maximal dose 4. Combination salvage chemoXRT

 What are the chances of tumor recurrence  What are the usual sites of recurrence  Local ▪ Treatment options ▪ Benefits  Distant ▪ Treatment options ▪ Benefits  Suggested follow up after treatment

 A 68 year old retired carpenter with a history of CAD, CABG, CHF, COPD, and DM presents with progressive GERD symptoms.  No dysphagia or weight loss.  EGD:  distal esophagitis with an area of ulceration just proximal to the GE junction  Biopsy: Moderately differentiated adenocarcinoma.  EUS:  T2 N0tumor

 PET/CT:  No abnormal FDG uptake in paraesophageal lymph nodes.  No distant metastases.  Surgical evaluation:  Not candidate for resection due to co-morbidities  Treatment:  Completes full course of combined chemotherapy and radiation.

 What are the chances of tumor recurrence  What are the usual sites of recurrence: 40%  Local ▪ Treatment options: ▪ Benefits  Distant ▪ Treatment options ▪ Benefits  Suggested follow up after treatment