What are the usual sites of recurrence What are the usual sites of recurrence LocalLocal distantdistant Benefits Benefits Palliative chemo ± radiationPalliative chemo ± radiation survival benefit survival benefit Quality of life Quality of life Treatment of recurrence in lymph node outside the initial field of initial radiotherapyTreatment of recurrence in lymph node outside the initial field of initial radiotherapy How- How- Physical Exam- what signs to look forPhysical Exam- what signs to look for CT chest/abdomen- what findings to look forCT chest/abdomen- what findings to look for EGD – what symptoms should prompt itEGD – what symptoms should prompt it Serum CEA levels- ? In which patientsSerum CEA levels- ? In which patients EUS - ? roleEUS - ? role How often How often Suggested protocols for follow upSuggested protocols for follow up

Post- treatment follow up of Esophageal cancer patients: medical considerations Edward Lin,MD Fred Hutchison Cancer Center Associate Professor of Medicine University of Washington Seattle, WA

* * Percent of failures %

Median OS is 9-11 month with modern chemotherapy. Median OS is 9-11 month with modern chemotherapy. Better response rate, TTP but modest OS benefits with QOL measures compared with other chemotherapy. Better response rate, TTP but modest OS benefits with QOL measures compared with other chemotherapy. BUT, chemotherapy versus best supportive care (BSC) suggest no OS benefits in two small randomized trials? BUT, chemotherapy versus best supportive care (BSC) suggest no OS benefits in two small randomized trials? Grunberger B Anticancer Res. 2007;27(4C):

N = 68. N = 68. Retrospective review Retrospective review Lymphadectomy or repeat Chemo-RT followed by chemotherapy is better than chemo or BSC. (p =.0001) Lymphadectomy or repeat Chemo-RT followed by chemotherapy is better than chemo or BSC. (p =.0001) But the study is small, retrospective and hypothesis generating in Asia. But the study is small, retrospective and hypothesis generating in Asia. Ann Surg Oncol Sep;15(9):2451-7

Physical exams. Physical exams. Blood work including CEA. Blood work including CEA. Routine use CT scan. Routine use CT scan. PET scan PET scan EUS EUS Endoscopy Endoscopy Palliative tools: EMR, stents, etc. Palliative tools: EMR, stents, etc.

CBC, LFT, CXR every 3-4 months CT scan chest, abdomen as needed clinically. McDonald JC NEJM 2004 McKernan BJC 2008;98: Healy LA Dis Esophaagus 2008 Epub GEJ Focused Physical Exam On multivariate survival analysis tumor stage P<0.0001) treatment (P<0.001) appetite loss (P<0.0001)

N = 90 N = 90 22% positive for CEA. 22% positive for CEA. CEA decline correlate with the response to Rx CEA decline correlate with the response to Rx Increase in CEA predicted relapse in lung, liver pleural space but not most pts with peritoneal involvement. Increase in CEA predicted relapse in lung, liver pleural space but not most pts with peritoneal involvement. BUT, it did NOT predict resectablity or survival. BUT, it did NOT predict resectablity or survival. Kim YH. et al. Cancer Jan 15;75(2): Clarke GW Am J Surg 1995;170:597.

CT alone has sensitivity 66% and specificity 95%. CT alone has sensitivity 66% and specificity 95%. Good at detecting celiac (69%), liver (73%) and lung (90%). Good at detecting celiac (69%), liver (73%) and lung (90%). US of the neck + CT results in 85% and 95% specificity. US of the neck + CT results in 85% and 95% specificity. EUS-limited. EUS-limited. Most cost effective, with modest QALYs and increasing cost. Most cost effective, with modest QALYs and increasing cost. Van Vliet EP et al. Br J Cancer. 2007;97(7):

Well established in preoperative staging. Well established in preoperative staging. Better than EUS Better than EUS ? In immediate post Rx re- evaluation. ? In immediate post Rx re- evaluation. ? Survival benefits in long term followup ? Survival benefits in long term followup

History: loss of appetite, fatigue, painHistory: loss of appetite, fatigue, pain Physical Exam- Weight loss, anemiaPhysical Exam- Weight loss, anemia CT neck/chest/abdomen- visceral metastasis, chest, celiac nodes.CT neck/chest/abdomen- visceral metastasis, chest, celiac nodes. EGD – dysphagia, aspiration pneumonia, chest pain, GOO.EGD – dysphagia, aspiration pneumonia, chest pain, GOO. EUS - ? With diagnostic dilemma.EUS - ? With diagnostic dilemma.

Q1

T1N0 GEJ The cure rate 80-90%.The cure rate 80-90%. If EMR or radiation cure rate 60-70% (then regular EGD is indicated).If EMR or radiation cure rate 60-70% (then regular EGD is indicated). Q 6 months for the first 2 years, then annual physical exams with routine blood work.Q 6 months for the first 2 years, then annual physical exams with routine blood work. Imaging only when clinically indicated.Imaging only when clinically indicated.

Q2

Chances of tumor recurrence (any): 20% Chances of tumor recurrence (any): 20% Sites of tumor recurrence Sites of tumor recurrence Local: 7%Local: 7% Distant: 14%Distant: 14% Treatment options Treatment options Salvage esophagectomy only selected cases reportSalvage esophagectomy only selected cases report Suggested follow up: Q3-4 month follow-up. CT scan as clinical indicated. CEA? Suggested follow up: Q3-4 month follow-up. CT scan as clinical indicated. CEA?

T3N0 tumor Overall 5 yr OS is 40% and Overall 5 yr OS is 40% and up to 80% if achieved pCR andup to 80% if achieved pCR and median OS 133 months.median OS 133 months. The goal of the follow-up to The goal of the follow-up to assess for local and systemic recurrence andassess for local and systemic recurrence and intervene on treated related complications.intervene on treated related complications. Suggest Suggest PE Q3-4 months (NCCN),PE Q3-4 months (NCCN), CEA if elevated preoperatively.CEA if elevated preoperatively. EGD only if symptoms.EGD only if symptoms. Routine CT scan Routine CT scan is not recommendedis not recommended but often done in the clinic.but often done in the clinic. PET surveillance is not recommended. PET surveillance is not recommended. Rationales: more options for systemic or local therapy. Rationales: more options for systemic or local therapy.

Q3

T3 N1 Overall 5 yr OS is 15-20% Overall 5 yr OS is 15-20% with risk for systemic (30-40%)with risk for systemic (30-40%) as well as local recurrence (30%).as well as local recurrence (30%). Suggest Suggest PE Q 4 months,PE Q 4 months, with blood work.with blood work. Routine CT scan chest/abdomen is often done Q 4 months. Routine CT scan chest/abdomen is often done Q 4 months. EGD only if symptoms.EGD only if symptoms. Routine PET surveillance is not recommended. Routine PET surveillance is not recommended. Option of systemic therapy Option of systemic therapy given the young age, and multiple systemic chemo regimens.given the young age, and multiple systemic chemo regimens.

Q4

T2N0+ medical comorbidites Overall 5 yr OS is 60% Overall 5 yr OS is 60% but decreased to 40% due to co-morbidities.but decreased to 40% due to co-morbidities. Increased systemic and local recurrence risk. Increased systemic and local recurrence risk. Suggest PE Q3-4 months with blood work. Suggest PE Q3-4 months with blood work. CT scan chest/abdomen and EGD only if symptoms. CT scan chest/abdomen and EGD only if symptoms. Rountine PET surveillance is not recommended. Rountine PET surveillance is not recommended.