Esophageal cancer medical therapy: Difference between revisions

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{{Esophageal cancer}}
{{Esophageal cancer}}
{{CMG}}
{{CMG}}{{AE}}{{HM}}


==Overview==
==Overview==
==Medical Therapy==
====General approaches====
The treatment is determined by the cellular type of cancer (adenocarcinoma or squamous cell carcinoma ''vs'' other types), the stage of the disease, the general condition of the patient and other diseases present. On the whole, adequate [[nutrition]] needs to be assured, and adequate dental care is vital.


If the patient cannot swallow at all, a [[stent]] may be inserted to keep the esophagus patent; stents may also assist in occluding fistulas. A [[nasogastric tube]] may be necessary to continue feeding while treatment for the tumor is given, and some patients require a [[gastrostomy]] (feeding hole in the skin that gives direct access to the stomach). The latter two are especially important if the patient tends to aspirate food or saliva into the airways, predisposing for [[aspiration pneumonia]].
The predominant therapy for esophageal cancer is surgical. [[Chemotherapy]] is used to treat advanced esophageal cancer. [[Chemotherapy]] can be used alone as monotherapy or in combination with [[Radiation therapy|radiotherapy]] or surgery. [[Chemotherapy]] may be used  as [[adjuvant]] therapy to shrink a tumor before being surgically resected  or as [[Neoadjuvant chemotherapy|neoadjuvant]] therapy after surgery to kill any cancerous cells that may have been left, and finally, in advanced tumors to shrink them or to relieve symptoms.
[[Image:SEMS endo.jpg|thumb|left|150px|[[Self-expandable metallic stent]]s are used for the [[palliative care|palliation]] of esophageal cancer]]
 
[[Image:esophagael stent.jpg|thumb|left|Shows cancer blocking esophagus. Insets show enlarged area of cancer and a stent placed in the esophagus to keep it open.]]
===Chemotherapy===
[[Chemotherapy]] depends on the tumor type, but tends to be [[cisplatin]]-based (or [[carboplatin]] or [[oxaliplatin]]) every three weeks with [[fluorouracil]] (5-FU) either continuously or every three weeks. In more recent studies, addition of [[epirubicin]] (ECF) was better than other comparable regimens in advanced nonresectable cancer.<ref>Ross P, Nicolson M, Cunningham D, Valle J, Seymour M, Harper P, Price T, Anderson H, Iveson T, Hickish T, Lofts F, Norman A. Prospective randomized trial comparing mitomycin, cisplatin, and protracted venous-infusion fluorouracil (PVI 5-FU) with epirubicin, cisplatin, and PVI 5-FU in advanced esophagogastric cancer. ''J Clin Oncol'' 2002;20:1996-2004. PMID 11956258.</ref> Chemotherapy may be given after surgery (adjuvant, i.e. to reduce risk of recurrence), before surgery (neoadjuvant) or if surgery is not possible; in this case, cisplatin and 5-FU are used. Ongoing trials compare various combinations of chemotherapy; the phase II/III REAL-2 trial - for example - compares four regimens containing [[epirubicin]] and either [[cisplatin]] or [[oxaliplatin]] and either continuously infused fluorouracil or [[capecitabine]].


==Radiotherapy==
==Medical Therapy==
[[Radiotherapy]] is given before, during or after chemotherapy or surgery, and sometimes on its own to control symptoms. In patients with localised disease but contraindications to surgery, "radical radiotherapy" may be used with curative intent.
Medical therapy for advanced esophageal cancer includes chemotherapy such as:<ref name="pmid8573528">{{cite journal |vauthors=O'Reilly S, Forastiere AA |title=Is surgery necessary with multimodality treatment of oesophageal cancer |journal=Ann. Oncol. |volume=6 |issue=6 |pages=519–21 |year=1995 |pmid=8573528 |doi= |url=}}</ref>
*[[Carboplatin]] and [[paclitaxel]]
**Combined with [[Radiation therapy|radiation]]
*[[Cisplatin]] and [[Fluorouracil|5-fluorouracil]] (5-FU)
**Combined with radiation
*ECF: [[epirubicin]], [[cisplatin]], and [[Fluorouracil|5-FU]]
**Especially for gastroesophageal junction tumors
*DCF: [[docetaxel]], [[cisplatin]], and [[Fluorouracil|5-FU]]
*[[Cisplatin]] with [[capecitabine]]
*[[Oxaliplatin]] and either [[Fluorouracil|5-FU]] or [[capecitabine]]
*[[Irinotecan]]
*For HER-2 positive esophagus cancers:
**[[Chemotherapy]] may be used along with the targeted drug [[trastuzumab]] or [[ramucirumab]].  
===Esophageal cancer===


==Follow-up==
* '''1 Stage IV Non - Her 2 Positive Esophageal Cancer'''<ref name="pmid9869669">{{cite journal |vauthors=Kelsen DP, Ginsberg R, Pajak TF, Sheahan DG, Gunderson L, Mortimer J, Estes N, Haller DG, Ajani J, Kocha W, Minsky BD, Roth JA |title=Chemotherapy followed by surgery compared with surgery alone for localized esophageal cancer |journal=N. Engl. J. Med. |volume=339 |issue=27 |pages=1979–84 |year=1998 |pmid=9869669 |doi=10.1056/NEJM199812313392704 |url=}}</ref><ref name="pmid9219702">{{cite journal |vauthors=Bosset JF, Gignoux M, Triboulet JP, Tiret E, Mantion G, Elias D, Lozach P, Ollier JC, Pavy JJ, Mercier M, Sahmoud T |title=Chemoradiotherapy followed by surgery compared with surgery alone in squamous-cell cancer of the esophagus |journal=N. Engl. J. Med. |volume=337 |issue=3 |pages=161–7 |year=1997 |pmid=9219702 |doi=10.1056/NEJM199707173370304 |url=}}</ref><ref name="pmid12444180">{{cite journal |vauthors=Hulscher JB, van Sandick JW, de Boer AG, Wijnhoven BP, Tijssen JG, Fockens P, Stalmeier PF, ten Kate FJ, van Dekken H, Obertop H, Tilanus HW, van Lanschot JJ |title=Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus |journal=N. Engl. J. Med. |volume=347 |issue=21 |pages=1662–9 |year=2002 |pmid=12444180 |doi=10.1056/NEJMoa022343 |url=}}</ref>
Patients are followed up frequently after a treatment regimen has been completed. Frequently, other treatments are necessary to improve symptoms and maximize nutrition.
** 1.1 '''Advanced esophageal cancer'''
*** 1.1.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): 21 day cycle of [[docetaxel]] 75mg/m2 IV on day 1, [[cisplatin]] 75mg/m2 IV on day 1 and [[fluorouracil]] 750mg/m2 IV q24h from day 1 through day 5.
***** Alternative regimen (1): 14 day cycle of modified [[docetaxel]] 40mg/m2 IV on day 1, [[leucovorin]] 400mg/m2 IV on day 1, [[fluorouracil]] 400mg/m2 bolus on day 1, [[fluorouracil]] 2000mg/m2 IV on day 1, [[cisplatin]] 40mg/m2 IV on day 3.
***** Alternative regimen (2): 21 day cycle of [[epirubicin]] 50 mg/m2 IV on day 1, [[cisplatin]] 60 mg/m2 IV on day 1, [[fluorouracil]] 200 mg/m2 q24h IV for up to 6 months.
***** Alternative regimen (3): 21 day cycle of [[epirubicin]] 50 mg/m2 IV on day 1, [[cisplatin]] 60 mg/m2 IV on day 1, [[fluorouracil]] 625 mg/m2 q24h PO on day 1 through day 21.
***** Alternative regimen (4): 21 day cycle of [[epirubicin]] 50 mg/m2 IV on day 1, [[oxaliplatin]] 130 mg/m2 IV on day 1, [[capecitabine]] 625 mg/m2 q24h PO on day 1 through day 21.
***** Alternative regimen (5): 42 day cycle of [[cisplatin]] 30 mg/m2 IV and [[irinotecan]] 65mg/m2 IV on days 1, 8, 15, and 22.
***** Alternative regimen (6): 21 day cycle of [[oxaliplatin]] 130mg/m2 IV on day 1, [[capecitabine]] 1000mg/m2 q24h PO on day 1 through day 14.
**: '''Note (1):''' Treatment is continued until disease progression, unacceptable toxicity or patient withdrawal.
* 2 '''Stage IV Her 2 Positive Esophageal Cancer'''
** 2.1 '''Advanced esophageal cancer'''
*** 2.1.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): 21 day cycle for 6 cycles; [[cisplatin]] 80 mg/m2 IV on day 1, [[capecitabine]] 1000mg/m2 q24h PO on day 1 through day 14, [[trastuzumab]] 8mg/kg IV loading dose on day 1 for cycle 1 only, followed by 6mg/kg IV on day 1 of every subsequent cycle starting with cycle 2.
***** Alternative regimen (1):21 day cycle for 6 cycles; [[cisplatin]] 80 mg/m2 IV on day 1, [[fluorouracil]] 800mg/m2 q24h IV on day 1 through day 5, [[trastuzumab]] 8mg/kg IV loading dose on day 1 for cycle 1 only, followed by 6mg/kg IV on day 1 of every subsequent cycle starting with cycle 2.
* 3 '''Weekly Carboplatin and Paclitaxel with concurrent Radiotherapy'''
** 3.1 '''Advanced esophageal cancer and esophagogastric junction cancer'''
*** 3.1.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[Paclitaxel]] 50mg/m2 IV and [[carboplatin]] AUC 2mg/ml x min IV on day 1, 8, 15, 22 and 29.
****:: '''Note (1):''' Given weekly for 5 weeks with concurrent [[Radiation therapy|radiotherapy]] followed by surgery.
***** Alternative regimen (1): [[Cisplatin]] 100 mg/m2 IV on day 1 through 29, [[Fluorouracil|5-FU]] 1000 mg/m2 q24h IV on day 1 through 4 and days 29 through 32 and [[Radiation therapy|radiotherapy]] 50.4 Gy.
****:: '''Note (2):''' 1.8 Gy for 5 days a week (final 5.4 Gy is given as a boost) on day 1 through 5, day 8 through 12, day 15 through 19, day 22 through 29. day 22 through 26, day 29 through 33, day 36 through 38.
****:: '''Note (3):''' Two courses of [[cisplatin]] and [[Fluorouracil|5-FU]] are given on days 1 and 29 of a 5.5 week course of radiotherapy.
****:: '''Note (4):''' Trimodality therapy with [[cisplatin]] and [[Fluorouracil|5-FU]] with concurrent radiotherapy followed by surgery.


==References==
==References==
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[[Category:Types of cancer]]
[[Category:Types of cancer]]
[[Category:Gastroenterology]]
[[Category:Gastroenterology]]
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Latest revision as of 16:40, 5 January 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]

Overview

The predominant therapy for esophageal cancer is surgical. Chemotherapy is used to treat advanced esophageal cancer. Chemotherapy can be used alone as monotherapy or in combination with radiotherapy or surgery. Chemotherapy may be used as adjuvant therapy to shrink a tumor before being surgically resected or as neoadjuvant therapy after surgery to kill any cancerous cells that may have been left, and finally, in advanced tumors to shrink them or to relieve symptoms.


Medical Therapy

Medical therapy for advanced esophageal cancer includes chemotherapy such as:[1]

Esophageal cancer

  • 1 Stage IV Non - Her 2 Positive Esophageal Cancer[2][3][4]
    • 1.1 Advanced esophageal cancer
      • 1.1.1 Adult
        • Parenteral regimen
          • Preferred regimen (1): 21 day cycle of docetaxel 75mg/m2 IV on day 1, cisplatin 75mg/m2 IV on day 1 and fluorouracil 750mg/m2 IV q24h from day 1 through day 5.
          • Alternative regimen (1): 14 day cycle of modified docetaxel 40mg/m2 IV on day 1, leucovorin 400mg/m2 IV on day 1, fluorouracil 400mg/m2 bolus on day 1, fluorouracil 2000mg/m2 IV on day 1, cisplatin 40mg/m2 IV on day 3.
          • Alternative regimen (2): 21 day cycle of epirubicin 50 mg/m2 IV on day 1, cisplatin 60 mg/m2 IV on day 1, fluorouracil 200 mg/m2 q24h IV for up to 6 months.
          • Alternative regimen (3): 21 day cycle of epirubicin 50 mg/m2 IV on day 1, cisplatin 60 mg/m2 IV on day 1, fluorouracil 625 mg/m2 q24h PO on day 1 through day 21.
          • Alternative regimen (4): 21 day cycle of epirubicin 50 mg/m2 IV on day 1, oxaliplatin 130 mg/m2 IV on day 1, capecitabine 625 mg/m2 q24h PO on day 1 through day 21.
          • Alternative regimen (5): 42 day cycle of cisplatin 30 mg/m2 IV and irinotecan 65mg/m2 IV on days 1, 8, 15, and 22.
          • Alternative regimen (6): 21 day cycle of oxaliplatin 130mg/m2 IV on day 1, capecitabine 1000mg/m2 q24h PO on day 1 through day 14.
      Note (1): Treatment is continued until disease progression, unacceptable toxicity or patient withdrawal.
  • 2 Stage IV Her 2 Positive Esophageal Cancer
    • 2.1 Advanced esophageal cancer
      • 2.1.1 Adult
        • Parenteral regimen
          • Preferred regimen (1): 21 day cycle for 6 cycles; cisplatin 80 mg/m2 IV on day 1, capecitabine 1000mg/m2 q24h PO on day 1 through day 14, trastuzumab 8mg/kg IV loading dose on day 1 for cycle 1 only, followed by 6mg/kg IV on day 1 of every subsequent cycle starting with cycle 2.
          • Alternative regimen (1):21 day cycle for 6 cycles; cisplatin 80 mg/m2 IV on day 1, fluorouracil 800mg/m2 q24h IV on day 1 through day 5, trastuzumab 8mg/kg IV loading dose on day 1 for cycle 1 only, followed by 6mg/kg IV on day 1 of every subsequent cycle starting with cycle 2.
  • 3 Weekly Carboplatin and Paclitaxel with concurrent Radiotherapy
    • 3.1 Advanced esophageal cancer and esophagogastric junction cancer
      • 3.1.1 Adult
        • Parenteral regimen
          • Preferred regimen (1): Paclitaxel 50mg/m2 IV and carboplatin AUC 2mg/ml x min IV on day 1, 8, 15, 22 and 29.
          Note (1): Given weekly for 5 weeks with concurrent radiotherapy followed by surgery.
          • Alternative regimen (1): Cisplatin 100 mg/m2 IV on day 1 through 29, 5-FU 1000 mg/m2 q24h IV on day 1 through 4 and days 29 through 32 and radiotherapy 50.4 Gy.
          Note (2): 1.8 Gy for 5 days a week (final 5.4 Gy is given as a boost) on day 1 through 5, day 8 through 12, day 15 through 19, day 22 through 29. day 22 through 26, day 29 through 33, day 36 through 38.
          Note (3): Two courses of cisplatin and 5-FU are given on days 1 and 29 of a 5.5 week course of radiotherapy.
          Note (4): Trimodality therapy with cisplatin and 5-FU with concurrent radiotherapy followed by surgery.

References

  1. ↑ O'Reilly S, Forastiere AA (1995). "Is surgery necessary with multimodality treatment of oesophageal cancer". Ann. Oncol. 6 (6): 519–21. PMID 8573528.
  2. ↑ Kelsen DP, Ginsberg R, Pajak TF, Sheahan DG, Gunderson L, Mortimer J, Estes N, Haller DG, Ajani J, Kocha W, Minsky BD, Roth JA (1998). "Chemotherapy followed by surgery compared with surgery alone for localized esophageal cancer". N. Engl. J. Med. 339 (27): 1979–84. doi:10.1056/NEJM199812313392704. PMID 9869669.
  3. ↑ Bosset JF, Gignoux M, Triboulet JP, Tiret E, Mantion G, Elias D, Lozach P, Ollier JC, Pavy JJ, Mercier M, Sahmoud T (1997). "Chemoradiotherapy followed by surgery compared with surgery alone in squamous-cell cancer of the esophagus". N. Engl. J. Med. 337 (3): 161–7. doi:10.1056/NEJM199707173370304. PMID 9219702.
  4. ↑ Hulscher JB, van Sandick JW, de Boer AG, Wijnhoven BP, Tijssen JG, Fockens P, Stalmeier PF, ten Kate FJ, van Dekken H, Obertop H, Tilanus HW, van Lanschot JJ (2002). "Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus". N. Engl. J. Med. 347 (21): 1662–9. doi:10.1056/NEJMoa022343. PMID 12444180.


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