What are the usual sites of recurrence What are the usual sites of recurrence LocalLocal distantdistant Benefits Benefits Palliative chemo ± radiationPalliative.

What are the usual sites of recurrenceWhat are the usual sites of recurrence• LocalLocal• distantdistant

BenefitsBenefits• Palliative chemo ± radiationPalliative chemo ± radiation

survival benefitsurvival benefit Quality of lifeQuality of life

• Treatment of recurrence in lymph node outside the initial field of initial Treatment of recurrence in lymph node outside the initial field of initial radiotherapyradiotherapy

How- How- • Physical Exam- what signs to look forPhysical Exam- what signs to look for• CT chest/abdomen- what findings to look forCT chest/abdomen- what findings to look for• EGD – what symptoms should prompt itEGD – what symptoms should prompt it• Serum CEA levels- ? In which patientsSerum CEA levels- ? In which patients• EUS - ? roleEUS - ? role

How oftenHow often• Suggested protocols for follow upSuggested protocols for follow up

Post- treatment follow up of Post- treatment follow up of Esophageal cancer patientsEsophageal cancer patients: :

medical considerations medical considerations

Edward Lin,MDEdward Lin,MDFred Hutchison Cancer Center Fred Hutchison Cancer Center Associate Professor of MedicineAssociate Professor of Medicine

University of WashingtonUniversity of WashingtonSeattle, WASeattle, WA

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Median OS is 9-11 month with modern Median OS is 9-11 month with modern chemotherapy.chemotherapy.

Better response rate, TTP but modest Better response rate, TTP but modest OS benefits with QOL measures OS benefits with QOL measures compared with other chemotherapy.compared with other chemotherapy.

BUT, chemotherapy versus best BUT, chemotherapy versus best supportive care (BSC) suggest no OS supportive care (BSC) suggest no OS benefits in two small randomized benefits in two small randomized trials? trials?

Grunberger B Anticancer Res. 2007;27(4C):2705-14.

N = 68. N = 68. Retrospective reviewRetrospective review Lymphadectomy or repeat Chemo-RT Lymphadectomy or repeat Chemo-RT

followed by chemotherapy is better than followed by chemotherapy is better than chemo or BSC. (p = .0001) chemo or BSC. (p = .0001)

But the study is small, retrospective and But the study is small, retrospective and hypothesis generating in Asia.hypothesis generating in Asia.

Ann Surg Oncol. 2008 Sep;15(9):2451-7

Physical exams.Physical exams. Blood work including CEA.Blood work including CEA. Routine use CT scan.Routine use CT scan. PET scanPET scan EUSEUS EndoscopyEndoscopy

Palliative tools: EMR, stents, etc.Palliative tools: EMR, stents, etc.

CBC, LFT, CXR every 3-4 monthsCT scan chest, abdomen as needed clinically.

McDonald JC NEJM 2004McKernan BJC 2008;98:888-93Healy LA Dis Esophaagus 2008 Epub

GEJ

Focused Physical Exam

On multivariate survival analysis

• tumor stage P<0.0001)

• treatment (P<0.001)

• appetite loss (P<0.0001)

N = 90N = 90 22% positive for CEA.22% positive for CEA. CEA decline correlate with the response to RxCEA decline correlate with the response to Rx Increase in CEA predicted relapse in lung, liver Increase in CEA predicted relapse in lung, liver

pleural space but not most pts with peritoneal pleural space but not most pts with peritoneal involvement. involvement.

BUT, it did NOT predict resectablity or survival.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 alone has sensitivity 66% CT alone has sensitivity 66% and specificity 95%. and specificity 95%.

Good at detecting celiac Good at detecting celiac (69%), liver (73%) and lung (69%), liver (73%) and lung (90%). (90%).

US of the neck + CT results in US of the neck + CT results in 85% and 95% specificity. 85% and 95% specificity.

EUS-limited.EUS-limited.

Most cost effective, with Most cost effective, with modest QALYs and increasing modest QALYs and increasing cost.cost.

Van Vliet EP et al. Br J Cancer. 2007;97(7):868-76.

Well established in Well established in preoperative preoperative staging. staging.

Better than EUSBetter than EUS

? In immediate ? In immediate post Rx re-post Rx re-evaluation.evaluation.

? Survival benefits ? Survival benefits in long term in long term followupfollowup

• History: loss of appetite, fatigue, painHistory: loss of appetite, fatigue, pain

• Physical Exam- Weight loss, anemiaPhysical Exam- Weight loss, anemia• • CT neck/chest/abdomen- visceral metastasis, CT neck/chest/abdomen- visceral metastasis,

chest, celiac nodes.chest, celiac nodes.

• EGD – dysphagia, aspiration pneumonia, chest EGD – dysphagia, aspiration pneumonia, chest pain, GOO.pain, GOO.

• EUS - ? With diagnostic dilemma. EUS - ? With diagnostic dilemma.

Q1Q1

T1N0 GEJT1N0 GEJ

• The cure rate 80-90%.The cure rate 80-90%.

• If EMR or radiation cure rate 60-70% (then regular EGD is If EMR or radiation cure rate 60-70% (then regular EGD is indicated).indicated).

• Q 6 months for the first 2 years, then annual physical Q 6 months for the first 2 years, then annual physical

exams with routine blood work.exams with routine blood work.

• Imaging only when clinically indicated. Imaging only when clinically indicated.

Q2Q2

Chances of tumor recurrence (any): 20%Chances of tumor recurrence (any): 20%

Sites of tumor recurrenceSites of tumor recurrence• Local: 7%Local: 7%• Distant: 14%Distant: 14%

Treatment optionsTreatment options• Salvage esophagectomy only selected cases reportSalvage esophagectomy only selected cases report

Suggested follow up: Q3-4 month follow-up. CT scan as Suggested follow up: Q3-4 month follow-up. CT scan as clinical indicated. CEA?clinical indicated. CEA?

T3N0 tumorT3N0 tumor

Overall 5 yr OS is 40% and Overall 5 yr OS is 40% and • up to 80% if achieved pCR and up to 80% if achieved pCR and • median OS 133 months. median OS 133 months.

The goal of the follow-up to The goal of the follow-up to • assess for local and systemic recurrence and assess for local and systemic recurrence and • intervene on treated related complications. intervene on treated related complications.

Suggest Suggest • PE Q3-4 months (NCCN), PE Q3-4 months (NCCN), • CEA if elevated preoperatively. CEA if elevated preoperatively. • EGD only if symptoms. EGD only if symptoms.

Routine CT scan Routine CT scan • is is not recommendednot recommended • but often done in the clinic. but often done in the clinic.

PET surveillance is PET surveillance is not recommendednot recommended. .

Rationales: more options for systemic or local therapy.Rationales: more options for systemic or local therapy.

Q3Q3

T3 N1T3 N1

Overall 5 yr OS is 15-20% Overall 5 yr OS is 15-20% • with risk for systemic (30-40%) with risk for systemic (30-40%) • as well as local recurrence (30%).as well as local recurrence (30%).

Suggest Suggest

• PE Q 4 months, PE Q 4 months, • with blood work. with blood work.

Routine CT scan chest/abdomen is often done Q 4 months. Routine CT scan chest/abdomen is often done Q 4 months. • EGD only if symptoms. EGD only if symptoms.

Routine PET surveillance is not recommended. Routine PET surveillance is not recommended.

Option of systemic therapy Option of systemic therapy • given the young age, and multiple systemic chemo regimens. given the young age, and multiple systemic chemo regimens.

Q4Q4

T2N0+ medical comorbiditesT2N0+ medical comorbidites

Overall 5 yr OS is 60% Overall 5 yr OS is 60% • but decreased to 40% due to co-morbidities.but decreased to 40% due to co-morbidities.

Increased systemic and local recurrence risk. Increased systemic and local recurrence risk.

Suggest PE Q3-4 months with blood work. Suggest PE Q3-4 months with blood work.

CT scan chest/abdomen and EGD only if symptoms. CT scan chest/abdomen and EGD only if symptoms.

Rountine PET surveillance is not recommended. Rountine PET surveillance is not recommended.