Download Visio-Ca Treatment Esophageal WEB Algorithm.vsd

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Esophageal Cancer
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note: Consider Clinical Trials as treatment options for eligible patients.
Consider referral to a Comprehensive Cancer Center
WORK UP
PRIMARY TREATMENT
ADDITIONAL
EVALUATION
CLINICAL
STAGE
Endoscopic mucosal
resection (EMR) and/or
Ablation or Esophagectomy
cTis to less than or
equal to cT1b
● History
and Physical
Swallow (optional)
● Esophagogastroduodenoscopy (EGD)
to visualize entire upper GI tract
● Biopsy confirmation and histologic
subtyping1
● CBC & chemistry profile
● Chest/abdominal CT with contrast
● Bronchoscopy, if tumor is at or above
the carina with no evidence of M1
disease
● Endoscopic ultrasound, if no evidence
of M1 disease and tumor is at
Gastroesophageal (GE) junction
● Biopsy confirmation of suspected
metastatic disease
● PET/CT
● HER2-neu evaluation by
Immunohistochemistry (IHC)2
in patients with advanced, metastatic
cancer (not localized cancer)
● Barium
● Multidisciplinary
cTis –
cT4, N0-1
evaluation is required
for all localized cases
(not for metastatic
patients)
● Nutritional assessment
(for preoperative
nutritional support,
consider nasogastric or
J-tube [PEG is not
recommended]
● Barium enema or
colonoscopy if colon
interposition or bypass
planned
● Arteriogram (optional)
consider if performing
colon interposition
1
Confirmation should be completed on outside MDACC specimen and inside MDACC specimen
Consider HER2-neu evaluation initially by IHC and later with FISH if clinically indicated
cT1b, AnyN
Yes
Esophagectomy3
No
Definitive
chemoradiation
Medically
Operable ?
cT2, N0
Surgery or combined modality therapy
Not medically
operable or patient
declining surgery
Definitive
chemoradiation
Medically operable
Preoperative
chemoradiation
● RT, 50-50.4 Gy
plus concurrent
chemotherapy
cT1b-T2, N+
cT3-T4, N0-3
Stage IV
Metastatic cancer
Follow-up, See page 3
Salvage Surgery4
Surgery4
Palliative treatment as
clinically indicated
2
See MDA Approved Biomarkers - https://www.mdanderson.org/education-and-research/resources-for-professionals/clinical-tools-and-resources/practice-algorithms/clin-management-biomarkers-web-algorithm.pdf
3
Preferred for noncervical cT1b disease
Patients who receive preoperative chemoradiation should be followed after surgery.
4
Copyright 2016 The University of Texas MD Anderson Cancer Center
Department of Clinical Effectiveness V4
Approved by The Executive Committee of the Medical Staff 06/28/2016
Esophageal Cancer
Page 2 of 6
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note: Consider Clinical Trials as treatment options for eligible patients.
Consider referral to a Comprehensive Cancer Center
SURGICAL OUTCOMES AFTER ESOPHAGECTOMY
CLINICAL
PATHOLOGIC FINDINGS
POSTOPERATIVE TREATMENT
Tis,T1,N0
Observe as clinically indicated
Adenocarcinoma
T2,N0
T3, N0
Yes
Surgery
as
primary
therapy
Squamous
● Observe
or chemoradiation (Fluoropyrimidine based) for selected patients.
● Adjuvant chemotherapy if patient received chemotherapy preoperatively
● Chemoradiation
(Fluoropyrimidine based).
● Adjuvant chemotherapy if patient received chemotherapy preoperatively
Observe as clinically indicated
Node negative?
Proximal or mid esophagus
Adenocarcinoma
Observe or chemoradiation (Fluoropyrimidine
based) for selected patients
No
Distal esophagus,
GE junction
Squamous
Macroscopic
residual cancer
Copyright 2016 The University of Texas MD Anderson Cancer Center
● Chemoradiation
● Adjuvant
(Fluoropyrimidine based).
chemotherapy if patient received chemotherapy preoperatively
Observe as clinically indicated
Chemoradiation (Flouropyrimidine-based)
or palliative therapy
Department of Clinical Effectiveness V4
Approved by The Executive Committee of the Medical Staff 06/28/2016
Esophageal Cancer
Page 3 of 6
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note: Consider Clinical Trials as treatment options for eligible patients.
Consider referral to a Comprehensive Cancer Center
FOLLOW - UP
● If
asymptomatic: History and
Physical every 4 months for 1
year, every 6 months for 2
years, then annually
● Chemistry profile and CBC, as
clinically indicated
● Imaging as clinically indicated
● Upper GI as clinically
indicated1
● Dilatation for anostomotic
stenosis
● Nutritional counseling
● Vitamin D level check
PALLIATIVE THERAPY
RECURRENCE
Concurrent chemoradiation (Fluoropyrimidine-based
preferred and/or best supportive care or surgery or
chemotherapy
Local/regional only recurrence:
prior surgery, no prior
chemoradiation
Yes
Esophageal recurrence:
(prior chemoradiation, no
prior surgery)
Salvage surgery
Resectable and
medically operable
No
Palliative therapy
Metastatic cancer
1
Patient with Tis or T1a who undergo EMR should have endoscopic
surveillance every 3 months for one year, then annually.
Copyright 2016 The University of Texas MD Anderson Cancer Center
Department of Clinical Effectiveness V4
Approved by The Executive Committee of the Medical Staff 06/28/2016
Esophageal Cancer
Page 4 of 6
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note: Consider Clinical Trials as treatment options for eligible patients.
Consider referral to a Comprehensive Cancer Center
SUGGESTED READINGS
PRINCIPLES OF MULTIDISCIPLINARY TEAM APPROACH FOR GASTROESOPHAGEAL CANCERS
Cooper JS, Guo MD, Herskovic A, et al. (1999). Chemoradiotherapy of locally advanced esophageal cancer: long-term follow-up of a prospective randomized trial (RTOG 85-01).
Radiation Therapy Oncology Group. JAMA; 281(17):1623-1627.
Macdonald JS, Smalley SR, Benedetti J, et al. (2001). Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction.
N Engl J Med; 345(10):725-730.
PRINCIPLES OF SURGERY
Birkmeyer JD, Siewers AE, Finlayson EVA, et at. (2002). Hospital volume and surgical mortality in the United States. N Engl J Med; 346:1128-1137.
Hofstetter WL. (2004). Lymph Node Dissection in Esophageal Cancer. Current Therapies in Thoracic and Cardiovascular Surgery, edited by SC Yang and DE Cameron.
Mosby, Inc., Philadelphia, Pennsylvania, pp. 360-363.
Hulscher JBF, van Sandick JW, de Boer AG, et al. (2002). Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus.
N Engl J Med; 347:1662-1669.
Risk NP, Ishwaran H, Rice T, et al. (2010). Optimum lymphadenectomy for esophageal cancer. Ann Surg; 25(1):46-50.
Swisher SG, Wynn P, Putnam JB, et al. (2002). Salvage esophagectomy for recurrent tumors after definitive chemotherapy and radiotherapy. J Thorac Cardiovasc Surg; 123:175-183.
CONTINUED ON NEXT PAGE
Copyright 2016 The University of Texas MD Anderson Cancer Center
Department of Clinical Effectiveness V4
Approved by The Executive Committee of the Medical Staff 06/28/2016
Esophageal Cancer
Page 5 of 6
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note: Consider Clinical Trials as treatment options for eligible patients.
Consider referral to a Comprehensive Cancer Center
SUGGESTED READINGS - CONTINUED
PRINCIPLES OF SYSTEMIC THERAPY FOR ESOPHAGEAL OR GASTROESOPHAGEAL JUNCTION CANCER
Al-Batran SE Hartmann JT, Probst S, et al. (2008). Phase III trial in metastatic gastroesophageal adenocarcinoma with fluorouracil, leucovorin plus either oxaliplatin or cisplatin:
a study of the Arbeitsgemeinschaft Internistische Onkologie. J Clin Oncol; 26(9):1435-42.
Cunningham D, Starling, N., Rao, S., et al. (2008). Capecitabine and oxaliplatin for advanced esophagogastric cancer. N Engl J Med; 358:36-46.
Dank M, Zatuski J, Barone C, et al. (2008). Randomized phase III study comparing irinotecan combined with 5-fluorouracil and folinic acid to cisplatin combined with 5-fluorouracil
in chemotherapy naive patients with advanced adenocarcinoma of the stomach or esophagogastric junction. Ann Oncol; 19(8):1450-1457.
Kang Y, Kang WK, Shin DB, et al. (2006). Randomized phase III trial of capecitabine/cisplatin (XP) vs. continuous infusion of 5-FU/cisplatin (FP) as first-line therapy in patients (pts)
with advanced gastric cancer (AGC): Efficacy and safety results. J Clin Oncol (Meeting Abstracts); 24(18_suppl):LBA4018.
Minsky BD, Pajak TF, Ginsberg RJ, et al. (2002). INT 0123 (Radiation Therapy Oncology Group 94-05) phase III trial of combined-modality therapy for esophageal cancer: high-dose
versus standard-dose radiation therapy. J Clin Oncol; 20: 1167-1174.
Van Cutsem E, Moiseyenko VM, Tjulandin S, et al. (2006). Phase III study of docetaxel and cisplatin plus fluorouracil compared with cisplatin and fluorouracil as first-line
therapy for advanced gastric cancer: a report of the V325 Study Group. J Clin Oncol; 24(31 ):4991-4997.
OTHER SUPPORTIVE READINGS
Peterson LA, Zeng X, Caufield-Noll CP, Schweitzer MA, Magnuson TH, & Steele KE. (2016). Vitamin D status and supplementation before and after bariatric surgery: a comprehensive
literature review. Surg Obes Relat Dis, pii: S1550-7289(16)00004-6. doi: 10.1016/j.soard.2016.01.001. [Epub ahead of print]
Copyright 2016 The University of Texas MD Anderson Cancer Center
Department of Clinical Effectiveness V4
Approved by The Executive Committee of the Medical Staff 06/28/2016
Esophageal Cancer
Page 6 of 6
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note: Consider Clinical Trials as treatment options for eligible patients.
Consider referral to a Comprehensive Cancer Center
DEVELOPMENT CREDITS
This practice algorithm is based on majority expert opinion of the Gastrointestinal Center Faculty at the University of Texas, MD Anderson Cancer Center. A multidisciplinary
approach was used and included input from the following medical oncologists, radiation oncologists, surgical oncologists, and pathologists:
Ŧ
Jaffer, Ajani , MD
Manoop Bhutani, MBBS
Prajnan Das, MD, MPH
Keith Fournier, MD
Ŧ
Linus Ho, MD
Wayne Hofstetter, MD
Jeffrey H. Lee, MD
Steven Lin, MD, PHD
Ŧ
Paul Mansfield, MD
Dipen Maru, MD
William A. Ross, MD
Heath Skinner, MD
Stephen Swisher, MD, BS
Dongfeng Tan, MD
James Welsh, MD
Core Development Team
Copyright 2016 The University of Texas MD Anderson Cancer Center
Department of Clinical Effectiveness V4
Approved by The Executive Committee of the Medical Staff 06/28/2016