The document summarizes the medical management of esophageal and gastric cancers. It outlines investigation, staging, treatment options including chemotherapy, immunotherapy, targeted therapy and surgery for localized, locally advanced and metastatic disease. Treatment approaches are described based on tumor stage, histology, fitness for surgery and prior therapies received. Guidelines for post-treatment surveillance and management of recurrence are also provided.

1. z
esophageal
cancer
Medical management of

2. z
Esophageal cancer
 Systemic therapy
1. Chemotherapy
2. Immunotherapy(Nivolumab-PD-L1,pembrolizumab –MSI H or
dMMR tumors or high mutation burden(TMB-H) -- dostarlimab –
gxly – MSI-H,,dMMR tumors.
3. Targeted theraphy (Trastuzumab-HER 2
overexpression,Ramucrirumab- VEGF receptors,Enterectinib NRT
inhibitors NTRK gene fussion positive tumors
 Preoperative therapy,perioperative therapy,post operative therapy

3. z
Esophagus carcinoma
( work up)
Newly diagnosed patients should undergo following investigation
1. CBC, biochemestry profile,endoscopy biopsy
2. CE ct scan, EU,FDG-PET/ CT
3. ER diagnostic for p stage and therapeutic
4. MSI and PD-L1 for metastatic ca and HER 2 for metatatic adeni
ca And genetic test

4. z
Classified patients in two clinical stages
 Locoregional cancer; stage l- 4a (except T4b or unresectable N3
 Medically fit for surgery
 Non sugical condidate
 Metastatic cancer;stage 4a(T4b or unresectable N3 only)and 4 B

5. z
Medically fit patients
 A; early stage ca ( pTis or p T1a)
 ER,ER followed by ablation,ablation Esophgectomy extwnsive or
nodular disease ( adeno pT1b supreficial ER ablation)
 B; pT1b ,N0 and cT1b-cT2, N0 low risk lesion
 Esophagectomy
 C;cT2,N0 high risk lesion and cT1b-cT2,N+ or cT3-cT4a,any tumors
 preoprative chemoradiation ,definitive chemoradiation
 D; c T4b Definitive chemoradiation ( unresectable) if trachea,
heart, great vessela and vertabrae invasion then only
chemotherapy

6. z
Non sugical condidate
 A: pTis,pT1a or pT1b, N0 SCC or Adeno ca
 A;Endoscopic therapies (ER) with or with out ablation
 B; cT1b-T4b,any N tumors
 Definite chemoradiation
 Pallative RT or palliative / best supportive care who canot tellorate
chemoradiation

7. z
Postoperative management
 Postoperative management is based on
 Surgical margins,parhologic tumor stage,nodal
status,histology,previos treatment

8. z
Scc no recevied pre op chemoradiatio
 R0 resection; Surveillance
 R1 ,R2 resection ; Fluoropyrimidine based chemoradiation
 Alternatively patients with R2 can receive pallative management

9. z
SCC who received preop chemo
radiation
 A: T0,N0 tumors
 Surveillance
 B: complet resected T+/ or N+ tumors
 Nivolumab
 C: R1 – R2 resection
 Observed untill disease progression or palliative management

10. z
Adeno ca no revevied pro op
chemoradiation
 A: R0, No resection;
 Surveillance
 B:pT3-pT4a Esophagus or GEJ high risk features ( pooely diff,LVI,perineural invasion,age less
than 50 years)
 Chemoradiation
 C: pT3-pT4a, node negative ---- chemotherapy
 D: R0 resection and N+, any Tumors
 Serveillence, chemoradiation, chemotherapy
 E: R1 resection – Chemoradiation / R2 resection – chemoradiation or palliative maaagement

11. z
Adeno CA who received preop
chemoradiation
 A: completed resected T+, N+ tumors – nivolumab/ observation
R0 resection N+ -- adjuvant chemoradiation no recommand
 R1 resection – obsevation or re-resection.
 R2 resection - palliative management

12. z

13. z
Follow – up surveillance
Stage 0-1(Tis,T1a and T1b)
 A: early stage ( Tis, T1a,and T1b) ER/ ablation or
chemoradiation---- EGD
 Esophagectomy --- EGD as clinically indicated base on
symptomes
 T1b tumors -ER,/ ablation ----EUS with EGD and consider
imaging studies but no to Tis or T1a

14. z
Stage ll- lll(T2-T4a,N0-N+,T4b)
 A: T2-T4b any N tumors : - after bimodality treatment::
reccurence 95% occure within 2 years --- EDG 3 to 6 months
for 2 years and 6 months for 3rd years then as clinically indicated
imaging studies every 6 months for 2 years
 After trimodality treatment – 90% occure with in 3 years surger
immage studies every 6 months within 2 years for luminal
reccurence no EGD no locoregional recurrences unschedualed
evaluvation if patient become symptomatic

15. z
Principal of systemic therapy
 Preoperative chemoradiation( infusional fluorouraxil or cacitabin)
 Preferred regimens
 Paclitaxwl,carboplatin
 Fluorouracil and oxaloplatin
 Other recommended regimens
 Fluorouracil and cisplatin– category 1
 Irinotecan and cisplatin --- category 2 B
 Fluorouracil or capcitabin – 2 B

16. z
Contineu...
 Perioperative chemotherapy ( only adeno ca of thoracic or GEJ)
 Preferred regimens
 FLOT ( category 1)
 Fluorouracil and oxaloplatin
 Other recommended regimens
 5 fu and cisplatin ( category 1)

17. z
Conrineu
 Preoperative chemotheray
 Only for adeno ca of thoracic esophagus ca or GEJ ca
 5 fu and cisplatin ( category 2 B)

18. z
Contineu
 Definitive chemoradiation ( infusional 5 fu)
 Preferred regimens
 Paclitaxel and carboplatin
 5 fu and oxaloplatin ( category1)
 5 fu and cisplatin ( category1)
 Other recommended regimens
 Cisplatin with docetaxel or paclitaxel
 Irinetecan and cisplatin ( category 2B)
 Paclitaxel and fluoropyramidine (category 2 B)

19. z
Contineu...
 Post operative therapy
 Nivolomab only after preoperative chemoradiation with R0
resection or residual disease
 Other recommended regimens
 Capecitabin and oxaloplatin
 5fu and oxaloplatin
 Postoperative chemoradiation ( fluoropyramidine ( infusional 5 fu
oe capcitabin) befoe and after fluoropyramidine based
cheoradiation

20. z
Unresectable locally advance,reccurenr,
metastatic disease
 First line therapy ( oxaloplatin preferred to cisplatin)
 Preferred regimens
 HER 2 + Adeno ca
 flouropyramidine and oxaloplatin and trastuzumab
 Fluoropyramidine and cisplatin and trastuzumab
 HER 2 –
 Fluoropyramidine and oxaloplatin and nivolumab only for adeo ca
 Category 1 for PD L1 CPS more or equal 5 and category 2 for PD L1CPS less5
 Fluoropyramidine and oxaloplatin and pembrolizumab
 PD L1 CPS more or equal 10

21. z
Contineu ..
 Second line or subsequent therapy ( depend on perior therapy
and ps
 Preferred regimens
 Nivolumab for scc
 Pembrolizumab 2nd line for scc with PD L1 expression and CPS >10
 Ramcirumab and paclitaxel for adeno ca
 Fam tratuzumab deruxtecan nxki HER 2 + adeon ca
 Docetaxel, paclitaxel ,irinotecan and docetaxel and irinotecan

22. z
Contineu
 Useful.in cetain circumstances
 Entrectinib and larotrectinib for NTR kinase gene fussion poaitive
tumors
 Pembrolizumab for MSI- H and d MMR tumors

23. z
Medical management of gastric cancer
 Work up same as esophagus ca
 By initial work up patient classified in to three clinical stages
1. Localized cancer ( stage cTis or cT1a)
2. Locoregional cancer(c Y1b –cT4a; c M0)
3. Metastatic cancer ( stage cT4b; cM1)

24. z
Locoregional cancer classified in to
following groups
1. Medically fit patient resectable disease
2. Medically fit patient unresectable disease
3. Non sugical condidate( no telorate major surgery or fit patient
who decline surgery

25. z
Primary treatment
 Medically fit patient
1. cTis or T1a tumors -- ER
2. cT1b or cT2,N0--- surgery preferred
3. cT2,N+ or cT3 or higher,any N tumors--- perioperative chemo

26. z
Non surgical condidte
1. cTis or cT1a ---- ER
2. Locoregional disease – palliative management/ best supportive
care
3. Metastatic disease ----- palliative management or best
supportive care
RESPONSE ASSESSMENT

27. z
Post operative management
 Post operative maaagement is based on pathlogic tumor
stage,nodal status,surgical margin, extent of lymphnode
dissection and previous treatment

28. z
Patients who no reveived preoperative
chemo or cheoradiation
 R1,R2 resection--- chemoradiati
 R0 resection pT2,N0 tumors high risk features( poorly
differentiated, LVI,NI,age less 50 years and not undergoing D2
lymph node dissection) or PT3,pT4,any N tumors or any pT,N+
tumors who recevied less than a D2 dissection ---- chemoradiation
 pT2,N0 without highrisk features --- surveillance
 pT3- pT4,any N or any pT,N+ tumors who undergone primary D2
lymoh node dissection --- post operative chemo
 R0 resection of pTis or pT1, N0 --- surveillance

29. z
Patient who receveid peroperative
chemo or chemo radiation
 Preoperative chemoradiation—R0 resection– observed untill
disease progression
 Preoprerative chemo ---R0 ressection --- post oprerative chemo
 R1 or R2 ,M 0 ---- pist oprerative chemoradiation
 Metastatic or R2 resection --- palliative management
 R1 ressection – reresetion

30. z
Chemotherapy regime
 Perioperative chemotherapy
 Preferred regimens ( FLOT,fluoropyramidine and oxaloplatin)
 Other recommended regimens ( Fluorouracil and cisplatin)
 Preoperative chemoradiation ( infusional fluorouracil,
capacitation)
 Other recommended regimens
 Pacli, carbo--- fluorouracil, oxalo---CF---fluoropyramidine

31. z
Contineu....
 Post operative chemoradiation
 Who receveid less than a D2 lymphnode dissection
 Post operative chemotherapy
 Who undergone primary D2 lymphnode dissecrion
 Preferred regimens (capcitabin and oxaloplatin) – cat 1
 5 fu and oxaloplatin

32. z
Contineu...
 Chemoradiation for unresectable disease
 Infusional 5 fu
 Preferred regimens
 5 Fu, oxalo
 5 fu,cisplatin

33. z
Unresectable locally
advance,reccurence, metastatic
 First line therapy ( oxaloplatin preferred over cisplatin)
 Preferred regimens
 HER 2 + Adeno CA ( fluoropyrimidine and oxalo or cisp and
Trastuzumab
 HER 2 - (fluoropyramidine ,oxalo and nivolumab (( PD- L1 CPS
more than 5

34. z
Contineu...
 Secind line or subsquent therapy( depending on perior therapy
and ps
 Ramucirumab and pacli
 Fam trastuzumab deruxtecan nxki for HER 2 + adeno ca
 Paclitaxel
 irinotecan,
 dicetaxel

35. z
Contineu ....
 Useful in certain circumstances
1. Entrectinib or larotrectinib for NTRK gene fusion positive
rumors
2. Pembrolizumab or dostarlimab for MSI- H or d MMR tumors