Derived and updated by consensus of members of the Providence Thoracic Oncology Work Group with the aid of evidence-based American Society of Clinical Oncology (ASCO), National Comprehensive Cancer Network (NCCN) national guidelines and National Guidelines Clearing House.
General Principles:
- All cases should be reviewed by a multidisciplinary thoracic cancer group.
- All patients should be encouraged to participate in available clinical trials if eligible.
- All patients should undergo EGD with biopsy, CT and PET scan to diagnose and stage disease.
- EUS should be performed if there is no metastatic disease.
- All patients with suspicious nodes on CT (defined as 1cm or larger or radiographically suspicious in the opinion of the chest radiologist) or EUS should undergo pathologic staging, if possible, prior to consideration of resection of the primary tumor.
- PEG tubes should be avoided in operable patients, jejunostomies can be used if needed for nutrition.
- Surgery is appropriate for a subset of stage I-III patients.
- Cancer of the GE junction should be treated with combined modality therapy in good performance status patients if it predominantly involves the esophagus but must be differenctiated from gastric cancer, which should be treated with chemotherapy and surgery if possible.
Evaluation:
- All confirmed esophageal cancer patients should have laboratory tests including a CBC, chemistries, LFT’s, and serum calcium.
- CT of the chest and abdomen through the liver with contrast (unless contraindicated) should be performed.
- EUS should be performed in all patients, if no metastasis found elsewhere.
- Patients with cancer above the carina should undergo bronchoscopy with biopsy, if endotracheal disease is found.
- Laparoscopic staging of the peritoneum should be considered for patients with GE junction tumors (lower one-third).
- Patients with abnormal alkaline phosphatase, serum calcium or bony pain should undergo bone scans.
- Patients with abnormalities on bone scan corresponding to focal back pain should be considered for MRI scanning of the affected area to rule out cord compression.
- Patients with neurological symptoms should undergo MRI of the brain.
- Patients being considered for surgery should have pulmonary function testing, cardiac evaluation, nutritional evaluation and PET evaluation prior to surgery.
Potentially Resectable Esophageal Carcinoma:
Stage 0:
T1N0M0:
- Careful staging evaluation.
- Resection.
- Post-op observation.
- In non-surgical candidates, consider PDT or endoscopic mucosal stripping.
Stage I to III:
T1-3,N0M0, T1-3,N1M0:
- Careful staging followed by consideration of resection for T1N0 or combined modality therapy that may include surgery in selected patients.
- Refer for combined modality studies if available.
- Definitive XRT if medically inoperable and performance status too poor for combined modality therapy.
Inoperable:
T4N0-1M0:
- Definitive chemoradiotherapy.
- Clinical trials if available.
Post-Operative Treatment
R0 Resection:
- Observe with quarterly evaluation for 12 months then biannually for 24 months, then annual
R1 Resection or Gross Residual Disease:
Follow Up After Definitive Chemoradiotherapy (Preferred for all cervical esophageal cancers):
CR:
- Consider esophagectomy vs. observation
PR:
Progression:
- Salvage chemotherapy or trials vs. palliative local modalities (stents, PDT, lasers, RT, feeding tubes)
Stage IV:
- Chemotherapy trials if available vs. standard therapy +/- palliative modalities
Recurrent Disease:
- Surgery or ChemoRT for local only recurrence
- Palliative modalities for medically unfit or inoperable patients
Chemotherapy plus or minus palliative modalities for good PS patients with M1 disease
Revised February 2006
|
