Esophageal Poll

[ramsesthenice]

Curious what other institutions are doing because I feel like I see this more than I use to. Patient presents with metastatic esophageal cancer. Gets palliative chemo. 4-6 cycles later they appear to have regional disease. Now what?

1) Keep going with chemo
2) palliative RT
3) Definitive chemoRT
4) Preop chemoRT

Let’s assume they are fit enough for all of the above.

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[Mandelin Rain]

Probably palliative chemoRT as per Walsh (15 fractions) followed by HER2 testing +/- next gen sequencing.

Would not do an esophagectomy in a metastatic patient in almost any case. Would have to be a pretty extreme case. Progression through chemo is not one of those cases.

 

[RickyScott]

I think if all pet positive disease is in one radiation field after chemo, 50 gy equivalent is not unreasonable if good kps.

 

[Palex80]

I would say this heavily depends on the amount/type of metastatic disease at presentation.

If it was just distant lymph nodes or a few lung nodules --> Go for RT. I'd rather do palliative RT than concurrent RCT for reasons of toxicity. But I'd give a "good" dose (for instance 15 x 3 Gy in patients with good KPS).

If it was widespread liver mets --> I would rather observe and switch to second line systemic therapy upon progression.

 

[KHE88]

The last time I did this in a patient with stable asymptomatic metastatic disease for a long time, I gave 4140 in 23. Med-onc gave concurrent Taxol, and in retrospect I think the taxol was a mistake. I would do it again to the same dose but without Taxol.

 

[w00tz]

Have done definitive chemoradiation in a couple of cases this year and the results have been not that great. They failed outside the radiation field shortly after finishing chemoRT. I would maybe consider sandwiching the chemoRT with chemo/systemic therapy?

 

[thecarbonionangle]

Chemo xrt but hypofractionate so they can return to systemic therapy after asap

 

[ramsesthenice]

I would say this heavily depends on the amount/type of metastatic disease at presentation.

In my experience biology almost makes this a non-issue. I try to never say never, but I can't think of a time any of these super responders had visceral metastases. We are virtually always talking about non-regional lymph nodes.

My personal approach to these has morphed over time. I initially agreed to try chemoRT for aggressive palliation on a couple folks with the thought they were probably going to live a while. I always went into it with the understanding that if/when toxicity became an issue we would stop and count whatever they got as palliaiton. I have probably done this 10 times or so and never had any issues.

The bigger question in my mind comes down to surgery. I have combed the data and its not that helpful. There are some institutional things but they are old and don't really apply to this group of patients. Mayo had one series that didn't look great but in the very small subset (<10, so has to be taken with a grain of salt) of patients who got surgery after a good response to chemo and radiation, survival wasn't that different from traditional esophageal patients. We are not operating on these folks. Around half of them have ended up being complete responders and we just monitor with imaging and EGDs. In a way, this isn't that surprising since we selected the patients who responded well in the first place. These guys are easy because patients and providers alike feel comfortable just watching things. The ones that fail tend to fail quick as one would expect and again its easy to know what to do here. The harder cases are the few where there is a little residual uptake in the esophagus but nothing else distant. We keep them on chemo after RT and over 6+ months still nothing else comes up. Its real hard to know what to do with them. Our thoughts are to keep close tabs on these folks and see if we can convince ourselves that they really do well enough long-term to consider surgery a reasonable option. To be clear, we are talking about an exceedingly small number of patients.

As to fields, I personally only treat what is avid at the time of radiation. I do not chase non-regional disease that "resolved" after chemo. I am still operating under the assumption that radiation is probably palliative.

 

[Grubbe-a-dub-dub]

I have a similar case right now with a young guy with bad dysphagia from a distal esophageal adeno requiring a J-tube. He has non-regional lymph node mets in the retroperitoneum.

We wanted to do long course chemoRT to the esophageal tumor for "aggressive palliation" but evicore is not allowing more than 15 fractions. I don't have experience with the Walsh regimen, ok to go above 2 Gy per fx with chemo? I want to avoid unnecessary toxicity since he's not curable.

 

[thecarbonionangle]

I have a similar case right now with a young guy with bad dysphagia from a distal esophageal adeno requiring a J-tube. He has non-regional lymph node mets in the retroperitoneum.

We wanted to do long course chemoRT to the esophageal tumor for "aggressive palliation" but evicore is not allowing more than 15 fractions. I don't have experience with the Walsh regimen, ok to go above 2 Gy per fx with chemo? I want to avoid unnecessary toxicity since he's not curable.

46/15

 

[RickyScott]

In my experience biology almost makes this a non-issue. I try to never say never, but I can't think of a time any of these super responders had visceral metastases. We are virtually always talking about non-regional lymph nodes.

My personal approach to these has morphed over time. I initially agreed to try chemoRT for aggressive palliation on a couple folks with the thought they were probably going to live a while. I always went into it with the understanding that if/when toxicity became an issue we would stop and count whatever they got as palliaiton. I have probably done this 10 times or so and never had any issues.

The bigger question in my mind comes down to surgery. I have combed the data and its not that helpful. There are some institutional things but they are old and don't really apply to this group of patients. Mayo had one series that didn't look great but in the very small subset (<10, so has to be taken with a grain of salt) of patients who got surgery after a good response to chemo and radiation, survival wasn't that different from traditional esophageal patients. We are not operating on these folks. Around half of them have ended up being complete responders and we just monitor with imaging and EGDs. In a way, this isn't that surprising since we selected the patients who responded well in the first place. These guys are easy because patients and providers alike feel comfortable just watching things. The ones that fail tend to fail quick as one would expect and again its easy to know what to do here. The harder cases are the few where there is a little residual uptake in the esophagus but nothing else distant. We keep them on chemo after RT and over 6+ months still nothing else comes up. Its real hard to know what to do with them. Our thoughts are to keep close tabs on these folks and see if we can convince ourselves that they really do well enough long-term to consider surgery a reasonable option. To be clear, we are talking about an exceedingly small number of patients.

As to fields, I personally only treat what is avid at the time of radiation. I do not chase non-regional disease that "resolved" after chemo. I am still operating under the assumption that radiation is probably palliative.

even in the localized setting, I dont know of data that chemo/xrt + surgery improves vs chemo/xrt alone, so would not consider it in metastatic setting. if trying to intensify treatment would consider adding io after xrt like in pacific trial, and you may get that approved in stage 4 setting.

 

[scarbrtj]

I have a similar case right now with a young guy with bad dysphagia from a distal esophageal adeno requiring a J-tube. He has non-regional lymph node mets in the retroperitoneum.

We wanted to do long course chemoRT to the esophageal tumor for "aggressive palliation" but evicore is not allowing more than 15 fractions. I don't have experience with the Walsh regimen, ok to go above 2 Gy per fx with chemo? I want to avoid unnecessary toxicity since he's not curable.

TBH all the times I've recited the incantation "Acute toxicity is driven almost all by total dose and not dose per fraction in the sub-5Gy per fx range" and went ahead and treated, even w/chemo, I've never had a disaster nor even a real surprise.

1) Keep going with chemo
2) palliative RT
3) Definitive chemoRT
4) Preop chemoRT

1-3 all possible, 4 I'll never even consider

 

[ramsesthenice]

even in the localized setting, I dont know of data that chemo/xrt + surgery improves vs chemo/xrt alone, so would not consider it in metastatic setting. if trying to intensify treatment would consider adding io after xrt like in pacific trial, and you may get that approved in stage 4 setting.

We have not been successful with this yet but its only a matter of time. IO makes way more sense to me than a highly morbid local therapy.

Survival in the localized setting is an interesting but long discussion. pCR for adenos is only 25ish percent so its pretty hard to imagine that surgery doesn't improve survival for them (again, talking localized). SCC is a different story. pCR approaches 50%. Considering 50% will ultimately fail distantly, you are getting to a place where it would take a lot of patients to show a survival benefit which is probably what you see in the Stahl data. With a boatload more patients I bet you would see it but concede there is nothing on paper to really support that. This does bring up a great thought though. What kind of data in the metastatic setting with IO do you think it would take to get surgeons to agree to a non-operative trial for non-metastatic patients (CRT -> IO)?

 

[medgator]

I have a similar case right now with a young guy with bad dysphagia from a distal esophageal adeno requiring a J-tube. He has non-regional lymph node mets in the retroperitoneum.

We wanted to do long course chemoRT to the esophageal tumor for "aggressive palliation" but evicore is not allowing more than 15 fractions. I don't have experience with the Walsh regimen, ok to go above 2 Gy per fx with chemo? I want to avoid unnecessary toxicity since he's not curable.

50/20 is my go to aggressive Palliation scheme. Probably would do 40-45/15 if in 3 weeks

 

[Mandelin Rain]

Walsh was 267 cGy to 4005 cGy with 25% pCR. Easy. Well tolerated.

 

[evilbooyaa]

Can someone link walsh paper?

Not aware of 3Gy x 15 in esophageal cancer - we specifically underdose esophagus when doing this in NSCLC because of otherwise riproaring esophagiitis that is common. Would not be enthusiastic for that, even in a patient not getting chemo. Would 100% not do it in a patient getting chemotherapy.

These patients are almost always non-regional lymph nodes (lower RP node) involvement.

I would favor 3 - def. CRT. I would do 50/25 with chemo if tolerated.

I would never, ever do 4. Not sending a metastatic patient for an esophagectomy.

 

[Mandelin Rain]

https://www.nejm.org/doi/full/10.1056/NEJM199608153350702?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

Was adeno only.

I must be old if people haven't heard of/read this one.

 

[evilbooyaa]

https://www.nejm.org/doi/full/10.1056/NEJM199608153350702?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

Was adeno only.

I must be old if people haven't heard of/read this one.

It was published literally 24 years ago. Not sure what to tell ya on that one.

Anyways, this was 40Gy to isocenter in 15 fractions before the 3D plans came into being, which is more like 37.5/15. Which is tolerable.

I thought somebody said 45/15?