Gastrointestinal cancer-4-Esophagus

GASTROINTESTINAL CANCER PART-4

Welcome to the fourth part of educational series on GastroIntestinal Cancers.

Question: Now Dr. Chiragbhai, we discussed about Barrett’s esophagus and about evaluation of a patient with esophagus cancer. What are the treatment approaches?

Answer: Traditionally, surgery has been the mainstay of treatment. However, recently more and more patients are being treated with chemotherapy plus radiotherapy without surgery, or triple treatment including surgery as well.

Que: Can you tell us more about how to choose between treatment options?

Ans: A number of factors are involved, but most important are: 1. Site of disease and resectability 2. Patient Fitness 3. Patient Preference 4. Availability of Expertise – surgical vs. chemoradiotherapy

Site: For Upper 1/3 chemoradiotherapy is preferred. For Middle 1/3 either surgery or chemoradiotherapy can be offered. For Lower 1/3 surgery is frequently preferred.

Patient should be explained advantages and disadvantages of both approaches. Local expertise should also be kept in mind, e.g. surgery for esophagus cancer is a challenging one, and surgeon’s skill level and experience are important in deciding outcome.

Surgery can be transthoracic or transhiatal, both have their advantages and disadvantages, and more important is surgeon’s familiarity and comfort level with either approach.

Postoperative treatment is recommended for high risk patients e.g. microscopic or macroscopic residual disease, and few other factors.

Que: What about triple or trimodality therapy?

Ans: Trimodality therapy refers to a combination of all 3 approaches i.e. chemotherapy, radiotherapy and surgery. Considering modest overall survival with either approaches alone, studies were done to combine all three. Results are not consistent in randomized trials, but suggestive in some studies and meta-analysis to favor trimodality therapy i.e. chemoradiotheapy followed by surgery. However, this should be undertaken only with most expert team, and in very fit patients, as the mortality can be significantly high.

Que: Are there any differences with regard to lower 1/3 esophagus or G-E junction tumors, as they are frequently studied as part of stomach tumors as well?

Ans: Yes, they are treated somewhat differently e.g. Based on intergroup study by McDonald et al, postoperative chemoradiation is offered to such patients. Also, practice in Europe is different based on MAGIC trial. This includes perioperative chemotherapy i.e. 3 cycles of ECF chemotherapy, followed by surgery, followed by 3 more cycles of ECF.

Que: Is there a role for preoperative chemotherapy without radiotherapy?

Ans: There are at least two major positive studies i.e. MRC group and French group studies. Both showed increase in PFS and overall survival with preoperative chemotherapy without radiotherapy. RTOG trial did not show benefit.

Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 98243 12144, 98988 31496

Diplomate American Board of Oncology and Hematology. Ahmedabad.

Shyam Hem-Onc Clinic. 402 Galaxy, Near Nehrunagar Circle, Ahmedabad.

98243 12144; 98988 31496. drchiragashah@gmail.com