CA- Esophagus

1. CARCINOMA ESOPHAGUS
Presentor : Dr.Gowtham
Moderator: Dr.Vikas Choudhary

2. Epidemiology and incidence
• Esophageal cancer is the eighth most common cancer worldwide
• Incidence of 160/100,000 in parts of South Africa and China and 540/100,000 in
Kazakhstan.
• India 8-20 / 100,000 , 6th most common in males
• Squamous cell carcinoma still accounts for most esophageal cancers diagnosed.
• M:F – 3:1 (SCC) .. …..15:1 (adeno)
• Adeno – whites …..SCC – african American
Globocan 2018

3. Anatomy
• The esophagus is a thin-walled, hollow tube approximately 25 cm in length.
• It is lined with stratified keratinized squamous epithelium, extending from the
cricopharyngeus muscle at the level of the cricoid cartilage superiorly to the
gastroesophageal junction inferiorly.
• The esophageal wall is composed of three layers: the mucosa, submucosa, and
muscularis propria
• The mucosal layer contains the epithelium(M1), lamina propria(M2), and muscularis
mucosae(M3).
• The epithelium is separated from the lamina propria by a basement membrane. In the
portion of the esophagus containing columnar-type epithelium, the muscularis mucosae
may consist of two layers.
• Similarly, the submucosal layer may be divided into inner (SM1), middle (SM2), and
outer(SM3) layers. The muscularis propria consists of a circular inner layer and
longitudinal outer layer.
• The adventitia (periesophageal connective tissue) lies directly on the muscularis propria.
• No serosa is present, facilitating extraesophageal spread of disease.
• AJCC 8th  4 Parts : cervical , upper thoracic ,middle thoracic ,lower thoracic

4. Siewert’s classification
• Type I : From >1 cm up to 5 cm above
the gastroesophageal junction (Z line),
the tumor is classified as a carcinoma
of the distal esophagus
• Type II : Within 1 cm cephalad to 2 cm
caudad to the gastroesophageal
junction.
• Type III :Tumor center is located >2
cm below the gastroesophageal
junction
AJCC 8th
• Cancers with an epicenter in the
lower thoracic esophagus or
gastroesophageal junction or within
the proximal 2 cm of the stomach
(i.e.,cardia) and extending up to the
GE junction or esophagus are staged
as a carcinoma of the esophagus.
• If the epicenter is >2 cm distal to the
gastroesophageal junction, these are
classified as stomach cancers.

5. Staging
• AJCC(TNM)
• Tumor
• Lymph node(N0,N1)
• Metastasis
• Most widely accepted
ELLIS (WNM)
• Wall penetration
• Lymph node(N0,N1,N2)
• Metastasis

6. AJCC 8TH

7. AJCC -8th
SCC
• Grade ,location of tumour affect
outcomes
Adenocarcinoma
• Tumour location –not a prognostic
variable
Adenosquamous – staged as squamous only

8. p Stage yp Stage (post neoadjuvant)

9. Lymphatics
• The esophagus has an extensive, longitudinal
interconnecting system of lymphatics. The
esophageal lymphatic network is primarily
located within the submucosa .However,
channels are also present within the lamina
propria, facilitating spread of even superficial
cancers of the esophagus involving the
mucosa.
• In addition to these longitudinal lymphatics,
intramural lymphatics may traverse the
muscularis propria, facilitating tumor spread to
regional lymphatic channels and
paraesophageal nodes.
• Lymph can travel the entire length of the
esophagus before draining into lymph nodes,
the entire esophagus is at potential risk for
lymphatic involvement.
• Up to 8 cm or more of “normal” tissue can
exist between gross tumor and
micrometastases “skip areas”.
• Lymphatics of the esophagus drain into nodes
that usually follow arteries,including the
inferior thyroid artery, the bronchial and
esophageal arteries, and the left gastric artery
(celiac axis).

10. LN Status
• Depth of tumor penetration (T stage)
affects lymph node involvement (LNI)
• Intramucosal T1 lesions (18% LNI)
• submucosal T1 lesions (55% LNI)
• T2 lesions (60% LNI)
• T3 lesions (80% LNI)
• Chance if LN <50% - conservative eso
resection and limited lymph node dissection
• LN>50% - neoadjuvant therapy followed by
resection

11. Natural history and pattern of spread
• Squamous cell carcinoma is characterized by
extensive local growth and proclivity to lymph node
metastases.
• Because the esophagus has no covering serosa,
direct invasion of contiguous structures may occur
early.
• Lesions in the upper esophagus can impinge on or
invade the recurrent laryngeal nerves,carotid
arteries, and trachea. If extraesophageal extension
occurs in the mediastinum, tracheoesophageal or
bronchoesophageal fistula may occur.
• Tumors in the lower one-third of the esophagus can
invade the aorta or pericardium, resulting in
mediastinitis, massive hemorrhage, or empyema.

12. Histology • Squamous and adeno -95% of all carcinomas
• Psuedosarcoma – spindle cell carcinoma (SCC
variant)
• Adenoca variants –Adenoid cystic
,mucoepidermoid poorer prognosis
• Small cell carcinoma – arise from argyrophilic
cells paraneoplastic syndromes !!
(ADH,hypercalcemia) , similar to SCLC
• Nonepithelial origin – very rare
• Malignant melanoms –MS 7months
• Lymphoma –mostly extension , as primary very
rare

13. SCC
• Squamous cell carcinomas arise from the squamous mucosa - native to the
esophagus - 70% - upper and middle thirds
• Most common type of esophageal ca in India (90%)
• Smoking and alcohol are common eitiologic factors (5 fold increase in risk)
• Combined increase risk from 25 - 100 folds
• Dietary
• Nitrosamines (pickled foods ,
smoked food)
• long term ingestion of hot liquids
• Micronutrient deficiency (Vit. A,
B12, C, E).
• Trace Element deficiency (Cobalt,
Copper & Selenium)
• Acquired
• Cigarette smoking
• Alcohol.
• Chronic esophagitis.
• Chronic Dysphagia
• Caustic ingestion
• Radiation exposure
• Plummer – vinson
syndrome
• Tylosis(40%)
• Achalasia (16 -fold)
• Esophageal strictures
and diverticula
• p53
• Premalignant conditions

14. Adenocarcinoma
• almost 70 % - United States and Western countries.
Etiology :
• Increasing incidence of GERD
• Western diet
• Increased use of acid-suppression medications
Histologically it is from :
• Submucosal glands of the esophagus
• Heterotopic islands of columnar epithelium
• Malignant degeneration of metaplastic columnar epithelium (Barrett’s esophagus) – 40
fold increased risk

15. Barret’s esophagus
• Traditionally - the presence of columnar mucosa extending at
least 3 cm into the esophagus.
• Recently - the specialized, intestinal-type epithelium
(presence of goblet cells) found in the Barrett’s mucosa is the
only tissue predisposed to malignant degeneration - the
diagnosis of BE is presently made given any length of
endoscopically identifiable columnar mucosa that is proven
on biopsy.
• 10 % of GERD pts develop – BARRETS
• Approx 1 in every 100 patient years of followup of barrets
develop adenocarcinoma (40 fold increased risk)

16. Clinical manifestations
• Early - asymptomatic – mimic GERD (3-4 months before diagnosis)
• Dysphagia >90% (mc)  > 2/3rds of lumen has to be obstructed (lack of serosa)
• Weight Loss (40-70%) -most common symptoms
• Vomiting/Regurgitation
• Pain.
• Cough , choking , asp.pneumonia (TEF)
• Hoarseness.(left.RLN , vocal cords)
• Dyspnoea
• In high-incidence areas where screening is practice,the most prominent early symptom is
pain on swallowing rough or dry food
• Systemic disease – jaundice ,excessive pain ,bone pain,respiratory symptoms
Perez & Brady 7E

17. Investigations
• Endoscopy
• CT
• PET
• MRI
• EUS

18. Esophagoscopy :
• Good 1st test – dysphagia & suspecting ca
esophagus
• Can differentiate intra luminal from
intramural & intrinsic from extrinsic
• Dx of esophageal ca is best made by
endoscopic biopsy
Critical points :
• Location of lesion
• Nature of lesion (polypoid etc)
• Extent & relationship to cricophayngeus ,GEJ
Apple core
appearance

19. :
CT
• Imp for staging.
• Chest and abdomen – Length , thickness, LN Liver
and lung mets , T4
• Accuracy  57%- T 74%- N , 83%- M
• Many unresectable tumors by CT scan are deemed
resectable at the time of surgery.

20. PET :
• FDG –PET:
• Evaluates Primary mass LN ,Mets
• Sensitivity and specificity slightly greater than CT
• Not reliable as single Dx tool
• Value in evaluating response to chemo and RT
• N staging imitations :periesophageal ln difficult to distinguish from primary mass , infections
• Detect distant metastasis in 20% pts
• (which was Not detected on CT )
• PET + CT – improve accuracy of detecting
• -stage III by 23%
• -stage IV by 18%
Figure Distant lymph node metastases of esophageal
cancer detected by integrated CT PET. A, Integrated CT
PET demonstrates para-aortic lymph node metastases
showing increased FDG uptake (arrowheads). B,
Corresponding CT image shows lymph nodes
(arrowheads) measuring 5 to 8 mm in diameter. Based
on size criteria, these lymph nodes may be considered
benign on CT scan

21. MRI
• Not done routinely
• To identify involvement of vascular & neural
• Accurately detects T4 and mets
• But overstages T & N status

22. EUS(Endoscopic Ultrasonography)
• More accurately assess
-periesophageal & celiac LN involvement
-transmural extent of ds.
• Limitation :
-less significant accuracy following neoadjuvant therapy d/t not
discriminate tumor from postradiation inflammation & fibrosis
• Overall accuracy for Local nodal (N) staging 75% to 80%
• Overall accuracy for Tumor staging (T) 85% to 90%

24. EMR :
• double-channel endoscope with a soft plastic cap at its tip. The cap is placed over
the top of the lesion, suction is applied, and a snare is brought down over the top of
the lesion
• A biopsy specimen of 1 to 1.5 cm will contain mucosa and submucosa
• may also be used as a therapeutic modality for premalignant and early
malignant conditions

25. Minimal invasive surgical modalities for
staging:
• Includes bronchoscopy ,Thoracoscopy and Laparoscopy.
• Highly accurate in evaluating N & M Status.

26. Molecular considerations
• HER2/neu oncogene : overexpressed in 15% to 30% of adenocarcinomas and 5% to
13% of SCC , Both IHC and FISH to be done , associated with tumor invasion,
lymph node metastases, and poor prognosis.
• EGFR :Overexpression of EGFR on IHC testing occurs in approximately 80% of
patients with adenocarcinoma and SCC , research for targeted therapies ongoing,
poor prognosis in terms of decreased survival.
• (VEGF) expression levels: poor prognosis , targeted therapy (ramucirumab)
• COX-2:Inhibition of COX-2 activity results in enhanced radiosensitization of tumor
tissue but not normal tissue.

27. MANAGEMENT OF CA
ESOPHAGUS
-Continuation……

28. Treatment options
• Surgery
• Radiation therapy
1.External Radiotherapy
2.Intraluminal Brachytherapy
• Chemotherapy
• Multimodality treatment combining above methods

29. Scheme of management
Perez 7th edition

30. SURGERY
RESECTABLE ESOPHAGEAL CANCERS: (STAGE I –III)
UNRESECTABLE ESOPHAGEAL CANCERS:

31. Endoscopic methods
• Endoscopic Mucosal Resection-
• CONSIDERED as essential diagnostic, staging and therapeutic option for patient having high
grade dysplasia, superficial esophageal tumor
• Procedure – injection of fluid in submucosal layer or use the suction to trap the lesion into
cylinder followed by tissue retrieval by snare or endoscopic knife
• Complete local remission rate – 99-100%
• 5 yr survival rate – 98%

32. SURGICAL RESECTION

33. CERVICAL ESOPHAGUS
 Proximal esophageal tumors are treated with DEFINITIVE
CHEMORADIOTHERAPY
 Total esophagectomy with resection of pharynx, larynx, thyroid gland is
required (Total pharyngo-laryngo-esophagectomy) – high morbidity with loss
of function.

34. THORACIC ESOPHAGUS
 IVOR LEWIS OPERATION
 Abdomen opened first and stomach mobilized
 And then Right thoracotomy -Oesophagogastric anastomosis
 2 stage approach
 McKeown OPERATION
 3 incisions
 Abdominal, right posterolateral thoracotomy
and left cervical incision

35. TRANSHIATAL ESOPHAGECTOMY without thoracotomy
( ORRINGER’S OPERATION )
 Avoidance of thoracotomy incision
 Avoidance of mediastinitis
 Shorter Duration of operation
 Poor visualization of upper and
middle esophageal tumors
 Anastomotic leak
 Chylothorax
 Recurrent laryngeal nerve injury
DisadvantagesAdvantages

36. Lymph node dissection
• En Bloc resection is the best treatment with
removal of all lymph nodesEn
bloc esophagectomy involves resection of
middle and lower esophageal tumors with an
envelope of adjacent tissue that includes the
mediastinal pleura laterally, the pericardium
anteriorly, and the azygos vein and thoracic
duct posterolaterally with the surrounding
periesophageal tissue and lymph nodes

37. Transhiatal vs transthoracic approach
Transhiatal approach Transthoracic approach
Thoracotomy not required Required
Distal esophagus Middle or distal esophagus
Less pulmonary complications more
Anastmotic leak high low
Disease free survival 1.4yr 1.7yr
Overall survival 1.8yr 2.0yr
5 yr survival rate 34% 36%
In hospital mortality 2% 4%
• Conclusion- either the transhiatal or transthoracic procedure can be performed with
acceptable mortality and morbidity , with either technique the outcome is almost
similar

38. Surgery Alone as Treatment
• 5 yr survival rate  28% , compared to 10% in patients treated medically.
• Locoregional failure rate  32-45%
• Need for adjuvant therapy
• Conclusion- as relapse rate is high and long term survival is poor ,
integration of adjuvant or neoadjuvant chemoradiation approaches in
treatment is rational and indicated.
• Optimum time for surgery ? (After NACRT)
Traditional 4-6 weeks Vs >12 weeks
Perez and Brady’s 7th edition

39. Radiation
 Pre op RT
 Pre op CT RT
 Post op RT
 Radical RT
 Radical CT RT
 Palliative
 Brachytherapy

40. Role of Preoperative Radiation Therapy
• In various trials comparing surgery alone vs
preoperative radiation followed by surgery it was
found that there is no clinical benefit of using
preoperative radiation.
• No significant survival benefit
• Local control rate was improved but non
significant.
• Conclusion- preoperative radiation therapy is not
recommended
• Dosage - 41.4-50.4 Gy/ 1.8-2.0 Gy per fraction/
23-28 Fr

41. Role of Preoperative Chemoradiation
• It is most common approach for resectable
esophageal cancer
• Benefits
downstaging of disease
increase rate of complete resection of disease
with negative margins
eradicate occult micrometastatic disease
• Improves local control
• Absolute Survival benefit  2yr - 13%
 5yr - 6.5%

43. Median Survival was 49 months as compared to 24
months in surgical arm – DOUBLED !!

44. Regimens
• Paclitaxel+carboplatin (cat-1)
Paclitaxel 50mg/m2 I V &+ Carboplatin AUC 2 Day-1 Wkly x 5 wk
• Cisplatin+ Fluorouracil (cat-1)
Cisplatin 75-100 mg /m2 D1&D29 + Fluorouracil 750-1000 mg /m2 IV infusion
over 24 hours daily on D1- 4 & D 29–32 {35day cycle} OR
Cisplatin 15 mg /m2 D1 - 5 + Flourouracil 800 mg /m2 IV infusion over 24 hours
daily on D1-5- 21days cycle x 2
• Fluorouracil+Oxaliplatin
Oxaliplatin 85 mg /m2 IV on D1 + Leucovorin 400 mg /m2 D1+ FU 400 mg /m2 IV
Push D1 and 800 mg /m2 IV continuous infusion over 24 hrs daily on D1 & D2
14 days cycle x 3 with radiation and 3 after radiation

45. Radiotherapy Alone as Treatment
• Indications- inoperable disease
- medical contraindication of surgery
- as palliative treatment
• Median survival – 6-12 month
• 5 yr survival - <10%
(I- 20%, II- 10%, III- 3%, IV- 0%)
• When compared to chemoradiation the 3 yr survival rate in radiation therapy alone
group was found 0%
• Conclusion- treatment with radiation therapy alone for esophageal cancer is palliative
in majority of patients and for radical treatment it should be used in conjunction with
other modalities.

46. Definitive Chemoradiation
Indications :-
• In squamous cell carcinoma
-cT1b-cT4a, N0-N+
- Cervical esophagus
- If patient refuses surgery
- cT4b
• In adenocarcinoma esophagus
- cT1b-cT4a, N0-N+
- If patient refuses surgery
- cT4b

47. Definitive Chemoradiation
• In comparison to radiation therapy alone –
 Improved median survival 14 vs 9 months
 Improved 5 yr survival rate 27 % vs none
• When compared to surgery alone in a resectable esophageal tumor no
difference in survival rate, local failure, treatment related mortality.
• 5 yr survival rate – 27%
• Radiation Dose – 50-50.4 Gy/ 1.8-2.0 Gy per fraction/25-28 Fr

48. CHEMOTHERAPY REGIMENS USED IN DEFINITIVE CHEMORADIATION
• Cisplatin+ Fluorouracil 5-FU (cat-1)
( Cisplatin 75-100 mg /m2 D1 + 5-FU 750-1000 mg /m2 IV infusion over 24 hours
daily on D1- 4 {28 day cycle} x 4) 2 cycles with RT F/b 2 cycles without RT
• Oxaliplatin + 5FU (cat-1)
Oxaliplatin 85 mg/m2 D1+ Leucovorin 400 mg/m2 IV D1
+ 5-FU 400 mg/m2 IV D1 + 5-FU 800 mg/m2 IV over 24 hours D1 & D2 2weekly -
3cycles with RT f/b 3cycles without RT
OR
Oxaliplatin 85 mg/m2 IV on D1,D15,D29 for 3 doses
Fluorouracil 180 mg/m2 IV Daily on D1-33

49. Post operative radiation therapy
• No survival advantage
• May decrease time to local recurrence particularly in cases with involved margins
• no significant decrease in local or distal failure rates
• Dosage - 45-50.4 Gy/ 1.8-2.0 Gy per fraction/ 25-28 Fr
Post operative Chemoradiation (in case of R1 ,Node positive(adeno carcinoma), pT3
,pT4a)
• When compared to surgery alone, surgery followed by chemoradiation group showed
• 5FU +Leucovorin based chemotherapy
• Significant decrease in local failure – 19% vs 29%
• Significant survival advantage – 27 vs 36 months
• Long term followup (>10yr) – continued to show survival advantage
• Conclusion- it is appropriate to advise adjuvant chemoradiation in view of improved local
control and survival

50. RADIOTHERAPY TECHNIQUES
PATIENT POSITIONING & IMMOBILISATION :
• Cervical /upper third :
Supine with arms by the side with straight cervical spine &
parallel to couch top + Immobilisation of jaw ,neck & upper
thorax
• Middle and lower third:
Supine with arms above their head + Vertebral column should
be as parallel to couch as possible
GEJ tumours and involving stomach fasting 2 hours before
simulation for reproducibility.

51. Upper Esophagus Radiation Field
• .Superior: 5 cm proximal to tumor +
supraclavicular LN + upper mediastinal
LN
Inferior: 5 cm distal to tumor
Lateral: Tumor + 2.5 –3 cm + mediastinal
LN + 2/3 of clavicle for SCF LN

52. Middle esophagus Radiation field
Superior: 5 cm proximal to
tumor + upper mediastinal LN
Inferior: 5 cm distal to tumor +
mediastinal LN
Lateral: tumor + 2.5–3 cm +
mediastinal LN

53. Lower esophagus RT
Superior: 5 cm proximal to tumor
+ mediastinal LN
Inferior: 5 cm distal to tumor +
mediastinal LN + celiac LN (until
L1–2 vertebrae)
Lateral: tumor + 2.5–3 cm +
mediastinal LN

54. Fields commonly used:-
• AP/PA fields followed by AP/Right posterior oblique(RPO)/Left posterior
oblique(LPO) with or without boost
• AP/PA approach followed by Right anterior oblique(RAO)/LPO fields with
or without boost
• 3-field technique (AP/PA with left lateral or oblique field)
• 45 Gy by AP/PA field followed by additional 5.4 Gy using oblique or lateral
fields –mc used.

55. AP/PA FIELDS AP AND TWO OBLIQUE FIELDS

56. Nodal basins to be covered under CTV:-
• Cervical & Upper Esophagus – lower cervical and supraclavicular to subcarinal lymph nodes + upper
paraesophageal lymph nodes
• Middle Esophagus – Complete coverage of paraesophageal lymph nodes ( individualized field design)
• Lower Esophagus – Subcarinal to left gastric and common hepatic artery/celiac lymph node inferiorly
• Adenocarcinoma – similar to lower thoracic esophagus but paraesophageal lymph nodes also to be
included
• Middle and lower paraesophageal lymph nodes should be included in Type 1 ,Type 2 tumor with T2-T4
• Splenic and common hepatic artery nodes can be spared in Type 1 T2 tumor
• GTV– primary gross tumor + nodal gross disease based on diagnostic studies
• CTV– to cover subclinical disease
 3-5 cm proximal and distal margins covers 94-100% subclinical disease.
 2 cm radial margin
• PTV– CTV + 1cm radial, 1.5cm distal , 1cm proximal margin (as per departmental protocols)
IMRT
NCCN 2019

57. External
Radiation
doses and OAR
constraints
• Higher doses 60-66 Gy in cervical esophagus , but there is
little evidence beyond dose of >50.4 Gy

58. Brachytherapy in Carcinoma
Esophagus
• Iridium 192 is used – high dose rate
brachytherapy is used most commonally
• Insertion- Transnasal or transoral route
• 1cm proximal and 1 cm distal margin is taken
based on pretreatment tumor length.

59. Ca Esophagus -Brachytherapy indications
Good candidates Poor candidates Contraindications
Primary tumor length ≤
10 cm length
Primary tumor length>
10 cm length
TE fistula
Tumor confined to
esophageal wall
Extra –esophageal
extension
Cervical esophagus
location
Thoracic esophagus
location
Regional
Lymphadenopathy
Stenosis which cannot
be bypassed
No nodal / systemic
metastasis
Tumor involving EGJ or
cardia

60. Definitive brachytherapy Palliative brachytherapy

61. Palliation
• 60 -80% rate of relief from dysphagia with radiation.
• MC received shedules were 20Gy/5# , 30Gy/10# , 35Gy/15# (with conc cisplatin or
FU) better relief of dysphagia in CRT group.
• Palliation by brachytherapy
• Stent placement –inferior compared to radiation /chemotherapy

62. Treatment sequale
• Esophagitis , dysphagia >75% , other usual symptoms  nausea , vomiting , weight
loss
• Cytopenias with 2 drug chemoregimens are more pronounced.
• Chemoradiation patients grade 3 – grade 4 toxities as high as 40%.
• Late side effects :Stricture formation 14- 30% ,stenosis 60%
• Rare – radiation pneumonitis (14% -grade 2) , cardiac toxicity 10% (pericardial
effusion , IHD , HF)
• TEF – 5-10% ( advised stenting , excision , bypass or intubation) , MS -10 weeks!

63. CHEMOTHERAPY

64. Role of Preoperative Chemotherapy
• In resectable esophageal cancer
(adenocarcinoma of esophagus and GE
junction)
• Benfits - Downstaging of disease to facilitate
resection
-Improvement of local control
-Relief of dysphagia
• The limiting thing is delay in definitive
treatment with risk of further spread of disease
specially in non responders
• Response rate – 50%
• Improve overall survival
• Absolute benefit – 2 yr survival – 7%
5 yr survival - 4%

65. Regimens
• Only for adenocarcinoma of thoracic esophagus- 2 cycles 21 days apart with
• Fluorouracil – 1000 mg/m2 IV continuous infusion over 24 hr daily on D1-
D4
• Cisplatin – 80 mg/m2 IV on Day 1

66. Postoperative Chemotherapy
• Based on various trials no survival benefit was found
• Disease free survival rate was improved speacially in patients who had R0
esection and was found nodepositive and can be considered for these patients
• No benefit in in patients with R0 resection and N0 node
Regimen
• Capecitabine and Oxaliplatin
Capecitabine 1000mg/m2 PO BID D1-14
Oxaliplatin 130mg/m2 IV D1
21 days cycle

67. Systemic Therapy for Recurrent or Metastatic disease
• First line therapy -Two drug regimen is preferred (lower toxicity)
• Three drug regimen reserved for medically fit patients with good
performance status
• Trastuzumab should be added in first line chemotherapy for HER 2
overexpressing metastatic adenocarcinoma
Drug -Single agents Response rate
Cisplatin 19 to 35 %
Paclitaxel 25 to 35 %
Docetaxel, 100 mg/m2 20-25%
Irinotecan 15%
Methotrexate less than 5%
Etoposide less than 5%
Ifosamide less than 5%
Carboplatin less than 5%

68. Regimens used as combination chemotherapy
First line therapy:-
Cisplatin and fluoropyrimidines (cat1)
• Cisplatin 75-100 mg /m2 IV D1 + Fluorouracil 750-1000 mg /m2 IV
continuous infusion over 24 hours daily on D1-4 – 28 DAY CYCLE
• Cisplatin 50 mg /m2 IV D1 + Fluorouracil 2000 mg /m2 IV continuous
infusion over 24 hours daily on D1+ Leucovorin 200 mg /m2 IV on D1 (14 day
cycle)
• Cisplatin 80 mg /m2 IV on D1+Capecitabine 1000 mg /m2 PO BID on D1-14
(21 days cycle)

69. Fluoropyrimidine and Oxaliplatin:-
• Oxaliplatin 85 mg /m2 IV D1 + Leucovorin 400 mg /m2 IV D1 +
Fluorouracil 400 mg /m2 IV push on D1 and 1200 mg /m2 IV continuous
infusion over 24 hr on D1&2 – (14 days cycle)
• Oxaliplatin 85 mg /m2 IV D1 + Leucovorin 200 mg /m2 IV D1 +
Fluorouracil 2600 mg /m2 IV continuous infusion over 24 hr on D1 –
(14 days cycle)
• Capecitabine 1000 mg /m2 PO BID D1-14 + Oxaliplatin 130 mg /m2 IV
D1 (-21 days cycle)
OTHER REGIMENS – DCF modifications-
 Docetaxel + cisplatin+ fluorouracil (OR) Docetaxel + oxaliplatin+ fluorouracil
(OR) Docetaxel + carboplatin+ fluorouracil
 Paclitaxel with cisplatin or carboplatin
 Epirubicin + cisplatin + fluorouracil

70. TRASTUZUMAB
• Used as first line therapy in recurrent or metastatic adenocarcinoma
esophagus overexpressing HER2
• When compared with 1st line combination chemotherapy, survival advantage
(13.8 vs 11.1 months) and response rate (47 vs 35%).
• Dosage – with chemotherapy
• 8 mg/kg IV loading dose on D1 of cycle 1 then 6mg/kg IV every 21 DAYS
OR
• 6mg/kg IV loading dose on D1 of cycle 1 then 4mg/kg every 14 DAYS

71. Second line therapy
• Ramucirumab + Paclitaxel ( Cat 1 for EGJ adenocarcinoma )
(Ramucirumab 8mg/kg IV on D1&15 + Paclitaxel 80 mg /m2 IV on D1,8,15 – 28
days cycle)
• Ramucirumab (Cat1 foe EGJ adenocarcinoma) – 8mg/kg IV on D1 – 14 days cycle
• Docetaxel – 75-100 mg /m2 IV on D1 – 21 days cycle
• Paclitaxel – 135-250 mg /m2 on D1 – 21 days cycle
• Paclitaxel – 80 mg /m2 IV on D1,8,15 cycled every 28 days
• Other regimens – irinotecan , irinotecan+fluorouracil, irinotecan +cisplatin,
docetaxel + irinotecan

72. Follow up and Surveillance
Tumor
classification
Therapy used Recommendations
Tis Endoscopic
resection(ER)/Ablat
ion
EGD X 6mnthly for 1-2 yr, then annually for 3 more yrs.
Esophagectomy EGD based on symptoms. If incomplete resection then EGD
every 6 mnths for 1-2 yr
T1a with or
without BE
ER/Ablation EGD every 3 mnthlyx1yr then every 4-6 mnths for 2nd yr then
annually for 3 more yrs
T1a Esophaegctomy EGD based on symptoms. If incomplete resection then
ablation f/b EGD every 3 mnthlyx1yr then every 4-6 mnths
for 2nd yr then annually for 3 more yrs
T1b , N0 ER/Ablation EGD every 3 mnthlyx1yr then every 4-6 mnths for 2nd yr then
annually for 3 more yrs. Further surveillance will depend on
relapse. PET-CT OR CT chest & abdomen yearly x 3yrs and
then if needed clinically

73. Follow up and Surveillance
T1b ANY N Esophagectomy PET-CT or CT chest and abdomen with contrast every 6
mnthly x 3yrs, then if clinically warranted. If incomplete
resection then ablation f/b EGD every 3 mnthlyx1yr then
every 4-6 mnths for 2nd yr then annually for 3 more yrs
Chemoradiation (non
surgical candidates)
EGD 6-12 months x 2 yrs then annually x3 yrs
PET-CT OR CECT chest and abdomen every 6-9 months x
2yrs then annually upto 5 yrs
Chemoradiation
(cadidate of salvage
esophagectomy)
EGD 6-12 months x 2 yrs then annually x3 yrs
PET-CT OR CECT chest and abdomen every 6-9 months x
2yrs then annually upto 5 yrs
T2-T4,N0-
N+,T4b
Bimodality therapy
(chemoradiation)
EGD every 3-4 mnthly x2 yr, every 6 monthly for 3rd yr , then
as clinically warranted. PET-CT OR CECT chest and abdomen
every 6-9 months x 2yrs then annually upto 5 yrs
T2-T4,N0-
N+,T4b
Trimodality therapy Imaging (PET-CT,CECT) every 4-6 monthly X 1 yr then 6-9
monthly for next 2 yr.

74. SUMMARY
• Often diagnosed in late stages, so poorer outcomes.
• Multimodality treatment is recommended and essential for carcinoma
esophagus.
• Pattern of failure - ~50% local failures needs improved local treatment .
• 75% succumb to distant metastasis as well , Molecular markers and newer
targeted therapies under study.

75. THANK YOU !!

76. NCCN 2019 -SCC

79. Adenocarcinoma