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Treatment Options by Stage

Added 06 March 2013

Treatment options are based on current evidence

Tis-T1, N0, M0

Esophagectomy is preferred

Endoscopic mucosal resection for superficial disease

Photodynamic therapy or other ablative therapy for superficial disease

Primary chemoradiation (GIEFUPRT) in those who are not candidates for esophagectomy (including squamous cell carcinomas of the proximal esophagus)

Radiotherapy alone in those who are not candidates for esophagectomy or chemotherapy

Nutrition consultation and placement of a feeding tube should be considered in patients undergoing multimodality treatment

T2, N0, M0

Consider pre-operative chemoradiation.

Esophagectomy

Primary chemoradiation (GIEFUPRT) in those who are not candidates for esophagectomy

Nutrition consultation and placement of a feeding tube should be considered in patients undergoing multimodality treatment

T3-4a or N+, M0

Preoperative multidisciplinary evaluation by surgery, medical oncology and radiation oncology is recommended for these patients with high-risk resectable disease for consideration of:

  • Neoadjuvant chemoradiotherapy (UGIENACTRT) followed by esophagectomy or
  • Peri-operative chemotherapy for adenocarcinoma of the distal esophagus or esophagogastric junction (GIGECC, GIGECF) with esophagectomy
  • Following preoperative therapy, restaging with CT and, preferably, with PET imaging is recommended prior to resection to assess clinical response

Primary chemoradiation (GIEFUPRT) in those who are not candidates for esophagectomy

Nutrition consultation and placement of a feeding tube should be considered in patients undergoing multimodality treatment

Unresectable, recurrent, or metastatic disease

Palliative radiation, endoscopic dilation or stenting can improve symptoms, such as dysphagia and bleeding, and quality of life. Palliative chemotherapy may be given to help improve symptoms and quality of life, and extend survival in appropriately selected patients.

  • Adenocarcinoma is more responsive to chemotherapy than squamous cell carcinoma.

Currently approved chemotherapeutic agents for advanced esophageal carcinoma include: 5-fluorouracil (5-FU), capecitabine, cisplatin, epirubicin, and irinotecan.

  • The most commonly used regimens are:
    • For squamous cell carcinoma: 5-FU and cisplatin (GIFUC)
    • For adenocarcinoma:
      • 5-FU and cisplatin (GIFUC)
      • Epirubicin, cisplatin and 5-FU (ECF) or capecitabine (ECC)
      • 5-FU and irinotecan (FOLFIRI)
  • The choice and sequence of chemotherapy is determined by disease-related factors, patient factors and patient preferences as assessed by the medical oncologist.

In 20-25% of patients with gastroesophageal junction adenocarcinoma, there is tumour over-expression of the HER2 protein. Patients with HER2 2+/FISH+ or 3+ disease may benefit from the addition of the targeted agent trastuzumab.

  • The most commonly used regimen combines trastuzumab with cisplatin, and 5-FU (UGIGAVCFT) or capecitabine (UGIGAVCCT)
  • Patients who are responding after 6 cycles of chemotherapy with trastuzumab may continue with maintenance single agent trastuzumab (UGIGAVTR) until disease progression.

Please refer to current treatment protocols for indications, dosing and eligibility criteria.

Consider treatment on a clinical trial, if available.

Symptom management, best supportive care, and involvement of palliative care services as indicated by patient’s clinical status.​

SOURCE: Treatment Options by Stage ( )
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