Esophageal Cancer Treatment Guidelines

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 (gastrostomy or gastrojejunostomy) tubes should be avoided in operable patients.   Jejunostomy tubes can be used if needed for nutrition.
  • Surgery is appropriate for a subset of stage I-III patients. If considered resectable, patients should have the opportunity to discuss details of neoadjuvant chemotherapy or chemoradiotherapy.
  • Cancer of the GE junction should be treated with combined modality therapy in good performance status patients.

Evaluation:

  • All confirmed esophageal cancer patients should have laboratory tests including a CBC, chemistries, LFT’s, serum calcium.
  • CT of the chest and abdomen with contrast (unless contraindicated) should be performed.
  • EUS should be performed in all patients, if no metastatic disease found with other staging tests.
  • PET should be performed in all patients if no metastatic disease found with other staging tests.
  • 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 a bone scan or PET scan.
  • Patients with abnormalities on bone scan corresponding to focal back pain should be considered for MRI of the affected area to better characterize a possible metastatic site and 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 and nutritional evaluation prior to surgery.

Potentially Resectable Esophageal Carcinoma:

Stage 0:

T1N0M0:

  • Careful staging evaluation.
  • Resection.
  • Post-op surveillance.
  • In non-surgical candidates, consider photodynamic therapy (PDT) or endoscopic mucosal stripping.

Stage I-III:

T2-3N0M0, T1-3N1M0

  • Careful staging followed by consideration of primary resection or combined modality therapy that may include surgery in selected patients.
  • Encourage participation in a combined modality clinical trial if available.
  • If primary resection, consideration of adjuvant chemoradiotherapy.
  • Radiation therapy (RT) if medically inoperable and performance status too poor for combined modality therapy.

Stage III-IVA and Inoperable

T4N0-1M0-1a:

  • Definitive chemoradiotherapy.
  • Encourage participation in clinical trial if available.

Stage IVB:

  • If acceptable performance status, clinical trial participation or standard chemotherapy.
  • If poor performance status, supportive care alone.

Post-Operative Treatment

R0 Resection:

  • In T1N0 disease, surveillance with quarterly evaluation for 12 months then biannually for 24 months, then annually.
  • Beyond T1N0 disease, careful consideration of adjuvant chemoradiotherapy or chemotherapy (including clinical trial consideration) after review of any pre-operative therapy, primary tumor location and pathologic features.

R1 Resection or Gross Residual Disease:

  • RT with chemotherapy
  • Follow Up after Definitive Chemoradiotherapy (Preferred for all cervical esophageal cancers):

CR:

Consider esophagectomy vs. observation
PR:

  • Esophagectomy if able

Progression:

  • Salvage chemotherapy or clinical trial participation vs. palliative local modalities (stents, PDT, lasers, RT, feeding tubes)

Recurrent Disease:

  • Surgery or chemoradiotherapy for local only recurrence
  • Clinical trial participation or standard chemotherapy for distant recurrence.
  • Palliative modalities for medically unfit or inoperable patients

Revised April 2009