MANAGEMENT OF CA
OESOPHAGUS
Presented by Dr Alauddin

TREATMENT OPTIONS

RADIOTHERAPY
• Historically RT alone had been used to treat pt with unfavourible features
who are not fit for surgery or T4b disease
• Overall, the 5-year survival rate for patients treated with conventional
doses of RT alone is 0% to 10%
• RTOG 85-01 trial-- all patients in the RT-alone arm who received 64 Gy at 2
Gy per day with conventional techniques died of cancer within 3 years.
• Therefore RT alone should generally be reserved for palliation or for
patients who are medically unable to receive chemotherapy

Combined Modality Therapy
Preoperative Chemoradiation Therapy
Preoperative Sequential Chemotherapy and Chemoradiation Therapy
Perioperative Chemotherapy
Preoperative Chemotherapy
Definitive Chemoradiation Therapy
 Postoperative Chemoradiation Therapy

PREOPERATIVE CHEMORADIATION THERAPY

PERIOPERATIVE CHEMOTHERAPY
MAGIC TRAIL
FLOT 4 TRIAL

FLOT 4 TRIAL Lancet 2019

• N 716
• stage cT2 or higher or nodal positive stage (cN+),resectable tumors
• Arm 1– 3×ECF f/b sx f/b 3×ECF (control )
• Arm 2 – 4× FLOT4 f/b sx f/b 4× FLOT4 (study arm)
• median overall survival 50 months(FLOT4) vs 35months(ECF)
(hazard ratio [HR] 0·77; 95% confidence interval)
• Serious advers effect 27% in both group
• Hospitalization due to toxicity 26% ecf (94 pt) and 25% in FLOT4 (

• Conclusion- In locally advanced, resectable gastric or gastro-
oesophageal junction adenocarcinoma, perioperative FLOT improved
overall survival compared with perioperative ECF/ECX
• NCCN – use in selected patients with good performance status

Definitive Chemoradiation Therapy
• It is a treatment option for unresectable ca oesophagus or T4b
disease
• For patients who are not fit for surgery
• In a retrospective comparison, definitive chemoradiation with
paclitaxel and carboplatin resulted in superior OS, disease-specific
survival, locoregional control, and palliation in patients with
unresectable esophageal cancer.

Post operative chemoradiation
• The landmark INT-0116 trial
• Surgery alone vs surgery f/b chemoradiation
• The majority of patients had T3 or T4 tumors (69%) and node-positive
disease (85%)
• After 5 yrs of follow up 5 year OS was 27 month vs 36 month
• The results of the INT-0116 trial established the efficacy of
postoperative chemoradiation in patients with resected gastric or EGJ
adenocarcinoma who have not received preoperative therapy.

SURGERY AFTER CRT

MOLICULAR AGENTS
• Currently used molecular testings are…
 HER2/ERBB2
 MSI/MMR ( microsatellite instability )
 PD-L1 expression
 TMB-H ( tumor mutational burden-high)
 NTRK (neurotrophic tropomyosin-related kinase)

HER2
Overexpression identified in development of ca oesophagus
Positivity rate
adenocarcinoma of the esophagus (15%–30%)
SCC (5%–13%)
Higher positivity in GEJ adenocarcinoma than gastric adenocarcinoma
Significantly higher positivity in males as compared to females
 testing is recommended for esophageal or EGJ adenocarcinoma
patients at the time of diagnosis if metastatic adenocarcinoma is
documented or suspected

TRANSTUZUMAB
• Used in HER2 overexpression positive advanced gastric and EGJ
adenocarcinoma.
• ToGA trial-- significant improvement in median OS with the addition
of trastuzumab to chemotherapy in HER2 overexpression positive
patients (13.8 vs.11 months, respectively; P = .046)
• HERXO trial-- At a median follow-up of 13.7 months, PFS and OS were
7.1 and 13.8 months, respectively (CAPOX with Transtuzumab)

• NCCN--trastuzumab should be added to first-line chemotherapy in
combination with a fluoropyrimidine and a platinum agent in
patients with HER2 overexpression positive adenocarcinoma
• Fam-trastuzumab deruxtecan can be used as 2nd line in her2 positive
case

RAMUCIRUMAB
 a VEGFR-2 antibody
 RAINBOW trial and REGARD trail – survival benefit ,can be
considered in 2nd line chemo
NIVOLUMAB
A monoclonal PD-1 antibody
Approved by USFDA on basis of checkmate 649 trail for first line
treatment of her2 negative PD L1 positive oesophageal carcinoma

 nivolumab was approved for patients with completely resected
esophageal or EGJ tumors with residual disease who had received
preoperative chemoradiation

CHEMO REGIMENS
• PREOPERATIVE CHEMORADIATION
Paclitaxel +carboplatin
FOLFOX
Cisplatin +5FU
• PERIOPERATIVE CHEMOTHERAPY
ECF
FLOT4
• POSTOPERATIVE THERAPY( after chemoRT and R0 resection)
 nivolumab

110-paraoesophageal
111-supradiaphragmatic
20-oesopha.hiatus
4sa short gastric vessel
1-R paracadinal
2-L paracardinal
3-lesser curvature
9-LN around celiac artery

thank you

questions
• Which of the following regimen is category 1 recommendation for pre
op chemoradiation
1. pacli+ carbo
2. FOLFOX
3. Cisplatin
4. All of the above


• Barrets oesophagus have risk of developing ca oesophagus
1.20-30 times
2. 30 -40 times
3. 30-60 times
4. 10 – 20 times


• Which trial deals with preoperative chemoRT
1. CROSS TRIAL
2. MAGIC TRIAL
3. FLOT4 TRIAL
4. ALL


• DOSE of rt used in CROSS trial
1. 50.4gy
2. 39 gy
3. 41.4 gy


• Which of the following agent is approved as a first line treatment in pt
with post op residual disease who had received preop chemoRT
1.Transtuzuma
2.Pertuzumab
3.Nivolumab
4.pembrolizumab
