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Post treatment follow up in esophageal cancer Ed Lin- 7 mins 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
Post- treatment follow up of Esophageal cancer patients: medical considerations Edward Lin,MD Fred Hutchison Cancer Center Associate Professor of Medicine University of Washington Seattle, WA
Pattern of failures Percent of failures % * *
Palliative chemotherapy Median OS is 9-11 month with modern chemotherapy. Better response rate, TTP but modest OS benefits with QOL measures compared with other chemotherapy. BUT, chemotherapy versus best supportive care (BSC) suggest no OS benefits in two small randomized trials? Grunberger B Anticancer Res. 2007;27(4C):2705-14.
Multimodality Rx for recurrent nodal disease N = 68. Retrospective review Lymphadectomy or repeat Chemo-RT followed by chemotherapy is better than chemo or BSC. (p = .0001) But the study is small, retrospective and hypothesis generating in Asia. Ann Surg Oncol. 2008 Sep;15(9):2451-7
Tools Physical exams. Blood work including CEA. Routine use CT scan. PET scan EUS Endoscopy Palliative tools: EMR, stents, etc.
Focused Physical Exam CBC, LFT, CXR every 3-4 months CT scan chest, abdomen as needed clinically. • On multivariate survival analysis • tumor stage P<0.0001) • treatment (P<0.001) • appetite loss (P<0.0001) GEJ McDonald JC NEJM 2004 McKernan BJC 2008;98:888-93 Healy LA Dis Esophaagus 2008 Epub
CEA N = 90 22% positive for CEA. CEA decline correlate with the response to Rx Increase in CEA predicted relapse in lung, liver pleural space but not most pts with peritoneal involvement. BUT, it did NOT predict resectablity or survival. Kim YH. et al. Cancer. 1995 Jan 15;75(2):451-6. Clarke GW Am J Surg 1995;170:597.
CT scan in follow-up CT alone has sensitivity 66% and specificity 95%. Good at detecting celiac (69%), liver (73%) and lung (90%). US of the neck + CT results in 85% and 95% specificity. EUS-limited. Most cost effective, with modest QALYs and increasing cost. Van Vliet EP et al. Br J Cancer. 2007;97(7):868-76.
PET Well established in preoperative staging. Better than EUS ? In immediate post Rx re-evaluation. ? Survival benefits in long term followup
Recommendations History: loss of appetite, fatigue, pain Physical Exam- Weight loss, anemia CT neck/chest/abdomen- visceral metastasis, chest, celiac nodes. EGD – dysphagia, aspiration pneumonia, chest pain, GOO. EUS - ? With diagnostic dilemma.
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.
Ed Lin Chances of tumor recurrence (any): 20% Sites of tumor recurrence Local: 7% Distant: 14% Treatment options Salvage esophagectomy only selected cases report Suggested follow up: Q3-4 month follow-up. CT scan as clinical indicated. CEA?
T3N0 tumor Overall 5 yr OS is 40% and up to 80% if achieved pCR and median OS 133 months. The goal of the follow-up to assess for local and systemic recurrence and intervene on treated related complications. Suggest PE Q3-4 months (NCCN), CEA if elevated preoperatively. EGD only if symptoms. Routine CT scan is not recommended but often done in the clinic. PET surveillance is not recommended. Rationales: more options for systemic or local therapy.
T3 N1 Overall 5 yr OS is 15-20% with risk for systemic (30-40%) as well as local recurrence (30%). Suggest PE Q 4 months, with blood work. Routine CT scan chest/abdomen is often done Q 4 months. EGD only if symptoms. Routine PET surveillance is not recommended. Option of systemic therapy given the young age, and multiple systemic chemo regimens.
T2N0+ medical comorbidites Overall 5 yr OS is 60% but decreased to 40% due to co-morbidities. Increased systemic and local recurrence risk. Suggest PE Q3-4 months with blood work. CT scan chest/abdomen and EGD only if symptoms. Rountine PET surveillance is not recommended.