ΜΑΘΗΜΑΤΑ ΟΓΚΟΛΟΓΙΑΣ: Γαςσπο-οιςουαγικόρ καπκίνορ ΓΝΑ Ιπποκπάσειο 19/2/13. Κίκα Πλοιαπφοπούλοτ

ΜΑΘΗΜΑΤΑ ΟΓΚΟΛΟΓΙΑΣ: Γαςσπο-οιςουαγικόρ καπκίνορ ΓΝΑ Ιπποκπάσειο 19/2/13 Κίκα Πλοιαπφοπούλοτ

Άνδπαρ, 72 εσών Καπνιςσήρ: 80 πακέσα/έση Α.Α: ΣΝ αγγειοπλαςσική (2000) Οπιςθοςσεπνικό άλγορ δτςυαγία Eνδοςκόπηςη: ενδοατλική μάζα μεςόσησαρ οιςουάγοτ Βιοχία: μέςηρ διαυοποποίηςηρ πλακώδερ Ca οιςουάγοτ

ΕUS EUS/FNA CT θώπακορ CT άνψ-κάσψ κοιλίαρ CT εγκευάλοτ Scanning οςσών PET/CT

Impact of EUS-guided fine-needle aspiration on lymph node staging in patients with esophageal carcinoma Gastrointestinal Endoscopy 2001; 53(7): 751-757

Methods: 74 patients with esophageal carcinoma underwent preoperative EUS. EUS-guided FNA was performed on nonperitumoral lymph nodes greater than 5 mm in width. Final diagnosis was based on surgical results or EUS-guided FNA malignant cytology. Final diagnosis was obtained in the remaining 64 patients (33 from the EUS only group and 31 from the EUS-FNA group). Results: The results of EUS versus EUS-FNA for lymph node staging were sensitivity 63% versus 93% (p = 0.01), specificity 81% versus 100% (not significant), and accuracy 70% versus 93% (p = 0.02), respectively. Conclusions: EUS-FNA is more sensitive and accurate than EUS alone for preoperative staging of locoregional and celiac lymph nodes associated with esophageal carcinoma. EUS-FNA of nonperitumoral lymph nodes in patients with esophageal carcinoma is safe and should be routinely performed when treatment decisions will be affected by nodal stage.

Impact of lymph node staging on therapy of esophageal carcinoma Gastroenterology 2003 ;125(6):1626-35.

METHODS: 125 patients patients with esophageal carcinoma were prospectively evaluated with CT, EUS, and EUS FNA. The impact of tumor stage on final therapy was assessed RESULTS: EUS-FNA was more sensitive (83% vs. 29%; P < 0.001) than CT and more accurate than CT (87% vs. 51%; P < 0.001) or EUS (87% vs. 74%; P = 0.012) for nodal staging Tumor location, patient age, comorbidities, and tumor stage determined by CT, EUS, and EUS FNA were associated with treatment decisions (P < 0.05). EUS FNA resulting in a higher/worse stage than CT (41 patients) was associated with a greater rate of treatments that were not direct surgeries compared with cases in which the stage was the same or better. CONCLUSIONS: EUS FNA is more accurate for nodal staging and impacts on therapy of patients with esophageal carcinoma. EUS FNA should be included in the preoperative staging algorithm of these patients.

Routine positron emission tomography does not alter nodal staging in patients undergoing EUS-guided FNA for esophageal cancer Gastrointestinal Endoscopy 2009; 69(7):1210-1217

RESULTS: Of 242 patients who underwent esophageal EUS for a malignant indication, 148 also underwent PET within 30 days. EUS detected locoregional-node disease by EUS criteria or cytology in 92 patients, and PET was positive in a minority of these patients (n = 41 [45%]). For celiac-node staging, PET was positive in 2 of 17 patients (12%) with celiac-node involvement detected by EUS. EUS was also significantly more sensitive than PET in the detection of nodal disease confirmed by cytology or histology (86% vs 44%). PET did not alter nodal staging in any patient with complete EUS- FNA. CONCLUSIONS: The addition of PET to a complete EUS examination did not alter regional-node or celiac-node staging. PET performance in overall staging is strongly associated with EUS assessment of lymph nodes.

JCO 2004;22(18):3805-12

ΕUS EUS/FNA CT θώπακορ CT άνψ-κάσψ κοιλίαρ CT εγκευάλοτ Scanning οςσών PET/CT

EUS: εξεπγαςία 4 εκ. με διήθηςη σοτ μτικού φισώνα και παποτςία 2 πεπιοιςουαγικών λεμυαδένψν, διαμέσποτ 1.7 και 2 εκ CT θώπακορ: πάφτνςη σοιφώμασορ μεςόσησαρ οιςουάγοτ CT άνψ-κάσψ κοιλίαρ με iv ςκιαγπαυικό: φψπίρ δετσεποπαθείρ ενσοπίςειρ

Οιςουαγεκσομή Oιςουαγεκσομή μεσεγφειπησική ΧΜΘ Οιςουαγεκσομή μεσεγφειπησική ΧΜΘ-ΑΚΘ Πποεγφειπησική ΧΜΘ-ΑΚΘ Πποεγφειπησική ΧΜΘ ΧΜΘ-ΑΚΘ

Multi-center, randomized, phase III trial 363 patients Paclitaxel (50 mg/m2) and Carboplatin (2AUC) on days 1, 8, 15, 22, 29 External beam radiation with a total dose of 41.4 Gy is given in 23 fractions of 1.8 Gy, 5 fractions a week pcr rate was 32.6% Mortality was 3.7% in the surgery alone arm versus 3.8% in the CRT arm R0 resection rate was 92.3% in the CRT arm versus 64.9% in the surgery alone arm. The overall survival was significantly better (p = 0.011) in the group of pts treated with CRT (median survival 49 months in the CRT arm vs 26 months in the surgery alone arm) ASCO Meeting proceedings 2010;28(15) suppl

195 patients were randomized 98 were assigned to surgery alone (S group) and 97 to neoadjuvant chemoradiotherapy group (CRT group; 45 Gy/25 F/5 weeks with 2 courses of concomitant chemotherapy 5-FU 800 mg/m 2 /day D1-D4 and cisplatin 75 mg/m 2 D1 or D2) Postoperative morbidity and 30 day-mortality rates were 49.5% (S group) vs. 43.9% (CRT group) (p = 0.17) and 1.1% (S group) vs. 7.3% (CRT group) (p = 0.054), respectively Median survivals were 43.8 (S group) vs. 31.8 months (CRT group) ( p = 0.66). ASCO Meeting proceedings 2010;28(15) suppl

9 RCTs - 1,116 patients A complete pathological response to chemoradiation occurred in 21% of patients. Neoadjuvant chemoradiation and surgery improved 3-year survival and reduced local-regional cancer recurrence. It was associated with a lower rate of esophageal resection, but a higher rate of complete (R0) resection. There was a nonsignificant trend toward increased treatment mortality with neoadjuvant chemoradiation. Concurrent administration of neoadjuvant chemotherapy and radiotherapy was superior to sequential chemoradiation treatment scheduling. Am J Surg 2003; 185(6):538-43

Gut 2004;53:925-930

4188 pts - 24 studies 1854 pts 12 studies on neoadj chemo-radiotherapy vs surgery 1981 pts 9 studies on neoadj chemo vs surgery 192 pts 2 studies on neoadj chemo-rt vs chemo Lancet Oncol 2011;12(7):681-92

5y OS for combined therapy was 26% vs 0% following RT Treatment failure was less common in the groups receiving combined therapy (34/130 [26%]) than in the group treated with RT only (23/62 [37%]) There were no significant differences in severe late toxic effects between the groups However, chemotherapy could be administered in only 68% of patients (10% had life-threatening toxic effects with combined therapy vs 2% in the RT only group) Conclusion Combined therapy increases the survival of patients who have squamous cell or adenocarcinoma of the esophagus, T1-3 N0-1 M0, compared with RT alone JAMA 1999; 5(17):1623-7

JCO 2002;20:1167-74

59 patients were staged II to IV and treated with definitive concomitant chemoradiotherapy RT: 50 64 Gy in 25 35 fractions Patients received two cycles of a 1-day regimen containing docetaxel (60 mg/m 2 ) and cisplatin (80 mg/m 2 ) Q 3 w ORR was 98.3%, with 42 complete responses and 26 partial responses Median overall survival time was 22.6 months Rates of locoregional progression-free survival, progression-free survival, and overall survival in 3 years was 59.6%, 29.2%, and 36.7% Hematologic toxicity Grade 3 and Grade 4 were observed in 39.0% and 20.3% of patients respectively Dis Esoph 2003;23(3):353-9

38 cisplatin/irinotecan and 19 carboplatin/paclitaxel) patients There were no significant differences in hematologic or nonhematologic toxicities between the groups. The 3-year overall survival estimates was 19.7% for the cisplatin/irinotecan group versus 56.1% for the carboplatin/paclitaxel group (P = 0.022) Estimated 3-year cancer-specific survivals were 24.6% for the cisplatin/irinotecan group versus 59.3% for the carboplatin/paclitaxel group (P = 0.033). Am JCO 2010;33(4):346-52;

The median overall survival was 17 months The median disease-free survival was 9 months The median time to local progression was 14 months Conclusions: Radiotherapy with concurrent weekly paclitaxel and carboplatin as definitive treatment for irresectable esophageal carcinoma is a tolerable regimen, which can be given on an outpatient basis and leads to durable locoregional control and palliation in about half of the patients ASCO Meeting proceedings 2010;28(15)suppl

ECRR: 45% VS 29% TTP: 15.2m vs 9.2m OS: 22.7m vs 15.1m

Οιςουαγεκσομή Oιςουαγεκσομή μεσεγφειπησική ΧΜΘ Οιςουαγεκσομή μεσεγφειπησική ΧΜΘ-ΑΚΘ Πποεγφειπησική ΧΜΘ-ΑΚΘ Πποεγφειπησική ΧΜΘ ΧΜΘ-ΑΚΘ

Ο αςθενήρ έλαβε 2 κύκλοτρ CDDP 75mg/m2 (d1) και Capecitabine 1000mg/m2 x2 (d1-14)

ΕUS EUS/FNA CT θώπακορ CT άνψ-κάσψ κοιλίαρ CT εγκευάλοτ Scanning οςσών PET/CT

Endoscopic Ultrasound Restaging After Neoadjuvant Chemotherapy in Esophageal Cancer 21 Am J Gastroenterol 2006;101(6):1216-

RESULTS: A total of 49 patients (43 men and 6 women) were evaluated with EUS pre- and post-neoadjuvant chemotherapy. Forty-seven patients had tumor localized at the GE junction and two had mid-esophageal lesions. Tumor and nodal staging accuracy post-chemotherapy were 60% T-stage accuracy post-chemotherapy was superior in patients without a response to chemotherapy (95.7% vs 26.1%, p<0.0001) More than 50% in reduction of tumor thickness postchemotherapy was associated with tumor downstage and better survival. N0 disease on final pathology was the best predictor of improved survival. CONCLUSION: Accuracy of EUS postchemotherapy is lower than initial staging accuracy; therefore the ability to predict downstaging based on EUS is marginal. Pathology N1 disease postchemotherapy is the best predictor of survival. EUS staging post-neoadjuvant chemotherapy should focus on improving nodal staging accuracy with FNA.

Post-treatment endoscopic biopsy is a poorpredictor of pathologic response in patients undergoing chemoradiation therapy for esophageal cancer. Ann Surg 2009 ;249(5):764-7

RESULTS: 156 patients were identified. Over 80% of patients received cisplatin-based chemotherapy and 5040 cgy of radiation. 118 patients had no tumor identified on endoscopic biopsy. A negative biopsy at endoscopy was a poor predictor of pcr - negative predictive value: 31% - with 69% having local disease at esophagectomy. A positive biopsy was predictive of residual disease positive predictive value: 95%. Negative endoscopic biopsy better predicted a pcr for squamous cell carcinomas versus adenocarcinomas. Nodal status of surgical specimens was not correlated with posttreatment endoscopic findings. Survival was equivalent after surgery in patients with a negative endoscopic biopsy versus patients with positive pathology. CONCLUSION: A negative endoscopic biopsy is not a useful predictor of a pcr after CRT, final nodal status, or overall survival.

The accuracy for nodal disease was 78%, 78%, and 93% for CT scan, EUS-FNA and FDG-PET/CT, respectively ( P =.04) FDG-PET/CT accurately predicted complete response in 89% compared with 67% for EUS-FNA ( P =.045) and 71% for CT ( P =.05) Conclusions FDG-PET/CT is more accurate than EUS-FNA and CT scan for predicting nodal status and complete responders after neo-adjuvant therapy in patients with esophageal cancer. J Thor Cardiovasc Surg 2005;129(6):1232-41

ΕUS EUS/FNA CT θώπακορ CT άνψ-κάσψ κοιλίαρ CT εγκευάλοτ Scanning οςσών PET/CT

CT θώπακορ: πάφτνςη σοιφώμασορ οιςουάγοτ CT άνψ-κάσψ κοιλίαρ: φψπίρ παθολογικά ετπήμασα

Oιςουαγεκσομή δύο πεδίψν οιςουαγογαςσπική αναςσόμψςη Ιςσολογική διάγνψςη: μέςηρ διαυοποποίηςηρ πλακώδερ καπκίνψμα οιςουάγοτ με διήθηςη σοτ μτικού φισώνα, όλοι οι εξαιπεθένσερ λεμυαδένερ είναι ελεύθεποι διήθηςηρ (Ν0/18) Τ2Ν0Μ0

METHODS: 4627 patients from the Worldwide Esophageal Cancer Collaboration database CONCLUSIONS: Greater extent of lymphadenectomy was associated with increased survival for all patients with esophageal cancer except at the extremes (TisN0M0 and >or=7 regional lymph nodes positive for cancer) and well-differentiated pn0m0 cancer. Maximum 5-year survival is modulated by T classification: resecting 10 nodes for pt1, 20 for pt2, and >or=30 for pt3/t4 is recommended. Ann Surg 2010;251(1):46-50

Cancer 2005;103:1347-1355

κάθε 3-6 μήνερ για 1-2 φπόνια κάθε 6-12 μήνερ για 3-5 φπόνια εσηςίψρ ςση ςτνέφεια O αςθενήρ είναι ελεύθεπορ νόςοτ εδώ και 3 φπόνια