Esophageal Cancer

Incidence

20640

Mortality

16,410

Percentage of all cancers in U.S.

1% (higher in other parts of the world)

Age related risk for diagnosis

69-70 years old

Esophageal cancer arisal

Caused by premalignant precursor lesions resulting from irritation and inflammation

Modifiable risk factors of esophageal adenocarcinoma

Baretts’s Esophagus, Obesity, Low fiber diet, GERD, dry cleaner or asbestos exposure

Modifiable risk factors of esophageal squamous cell carcinoma

Low fiber diet, smoking, alcohol, dry cleaning or asbestos exposure

Nonmodifiable risk factors for esophageal adenocarcinoma

Male gender, Tylosis, Howel-Evan’s syndrome, Bloom syndrome, Fanconi anemia, familial BE, achalasia (CA found 15-20 years later after begins), Plummer-Vinson Syndrome (webs), hx of other cancers, hiatal hernia, low physical activity

Nonmodifiable risk factors for squamous cell

Tylosis, Howel-Evan’s syndrome, Bloom syndrome, Fanconi anemia, familial BE, achalasia (CA found 15-20 years later after begins), Plummer-Vinson Syndrome (webs), hx of other cancers, hiatal hernia, low physical activity

Esophageal cancer prevention

• high fiber diet

• Healthy lifestyle

• Physical acitivity

• Avoid alcohol and tobacco

• Maintain healthy body weight

• Treat BE and GERD

• 2x a day PPI & NEAId for BE

Esophageal carcinoma diagnosis

• Endoscopy, thoraoscopy, or laparoscopy

• Chest/ABD CT w/ PO and IV contrast,

• MRI

• PET

• Endoscopic US

• Bronchoscopy

• Biopsy to confirm diagnosis

Histopathology of Squamous Cell CA

• common in developing countries

• Mid esophagus

Histopathology of Adenocarcinoma

• glandular epithelium

• Distal esophagus and GE junction

• Related to GERD and BE

Molecular classification of general metastatic disease is suspected

MSI-H and dMMR (respond to checkpoint inhibitors)

Molecular classification of adenocarcinoma metastatic disease is suspected

HER2 and PD1

Esophageal CA survival

19.9%

HER-2+ adenocarcinoma

Poor overall survival and increased mortality rate

Higher mortality rate in which ethnicity/gender group?

Black males

Surgery for Carcinoma in Situ in some S1 pts

Endoscopic resection/ablation

Surgery for pts with Stage 1-3 carcinoma

Esophagectomy

Neoadjuvant therapies with surgery

Radiation

Chemotherapy

Monoclonal Antibodies

Radiation

• used concurrent with therapy even if no surgery

• For palliative measures

Primary treatment for Stage IV

Chemotherapy

Systemic therapy for HER2+ Adenocarcinoma with Mets

Trastuzumab + Chemotherapy

Monoclonal antibodies for esophageal cancer

Trastuzumab

Racmucirumab

Pembrolizumab

Use of Ramucirumab

Alone or with paclitaxel

Use of Pembrolizumab

• Pts with MSI-H/dMMR for 2nd line therapy

• Pts with PD-L1 for 3rd line therapy

Preoperative Chemoradiation

Paclitaxel & Carboplatin

Cisplatin & 5-FU

Oxaliplatin & 5-FU

Perioperative chemotherapy schedule

3 cycles preoperatively and 3 cycles postoperative

Peri-operative combination regimens

Cisplatin & 5-FU

Epirubicin, Cisplatin, 5-FU, Oxaliplatin, and 5-FU

Definitive chemoradiation regimen

Cisplatin & 5-FU

Oxaliplatin & 5-FU(or capecitabine)

Cisplatin, Paclitaxel, & Carboplatin

Postoperative Chemoradiation

Infusional 5-FU or capecitabine

Metastatic chemo regimen

Docetaxel, Cisplatin, 5-FU

Epirubicin, Cisplatin, 5-FU or capecitabine

Oxaliplatin & 5-FU or capecitabine

Irinotecan & 5-FU