post-treatment management of esophageal cancers: surgical considerations

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