Date: Apr 17, 2025 • Issue no: #062
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In this issue: - Understand the workup of newly diagnosed esophageal adenocarcinoma
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Review the multimodal treatment of localized esophageal adenocarcinoma
- And more!
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Diagnosis and Management of localized esophageal adenocarcinoma |
Case #1
A 60-year-old male with a past medical history of well-controlled hypertension is meeting with his medical oncologist to decide on treatment for esophageal adenocarcinoma. Several months prior, he presented to a gastroenterologist with progressively worsening dysphagia and gastroesophageal reflux-like symptoms over a four-month period. An EGD revealed a lesion located in the mid-esophagus and histopathological examination of a biopsy from the lesion confirmed the diagnosis.
Subsequent evaluation with endoscopic ultrasound (EUS) staged the tumor as T3, without evidence suggesting involvement of regional lymph nodes (N0). PET-CT demonstrated increased metabolic activity in the primary esophageal lesion, with no evidence of nodal or distant metastatic disease. NGS testing revealed the tissue was MSI-low and MMR proficient. CPS score was 0. What is the most appropriate treatment for his oncologist to recommend?
- Esophagectomy with adjuvant CRT if high-risk features or positive margins present
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Four cycles of 5-fluorouracil, oxaliplatin, and docetaxel followed by resection and adjuvant nivolumab if no pathologic complete response on surgical pathology
- Four cycles of 5-fluorouracil, oxaliplatin, and docetaxel followed by resection and four additional cycles of 5-fluorouracil, oxaliplatin, and docetaxel
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Preoperative radiation with concurrent carboplatin and paclitaxel followed by resection
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Neoadjuvant nivolumab followed by resection
Scroll down to find the answer! Need to refresh your memory before answering this question? Head over to Pathway to review our section on localized esophageal adenocarcinoma and our recent Journal Club on the topic. |
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Case #1 Conclusion
Answer - C. Four cycles of 5-fluorouracil, oxaliplatin, and docetaxel followed by resection and four additional cycles of 5-fluorouracil, oxaliplatin, and docetaxel
Explanation: The 2025 ESOPEC Trial established the perioperative FLOT regimen (Four cycles of 5-fluorouracil, oxaliplatin, and docetaxel followed by resection and four additional cycles of 5-fluorouracil, oxaliplatin, and docetaxel) as the preferred regimen for patients with locally advanced, resectable esophageal carcinoma. Especially in this relatively healthy 60 year-old man with no contraindications to the intensive chemotherapy regimen and surgery, this regimen is preferred over the CROSS regimen (which is choice D). Choice A. would be the correct treatment for a T1 or T2 lesion. Choice B. is not an established regimen. Adjuvant nivolumab is only used after preoperative CRT if no pathologic complete response is seen on surgical specimen. Choice E. is incorrect, because although neoadjuvant immunotherapy is a consideration for some patients, the tumor’s low CPS, MSI-low, and MMR proficiency would indicate that it is less likely to respond strongly to immunotherapy.
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Case #2
A 60 year-old male with no significant past medical history is diagnosed with a cT2 N0 well-differentiated esophageal carcinoma with an estimated maximum diameter of 1.8cm based on EUS. He is evaluated by both surgical and medical oncology and ultimately it is decided he will be treated with up-front esophagectomy. During surgery, what is the minimum number of lymph nodes that should be removed and pathologically assessed for adequate nodal staging?
- 6
- 10
- 12
- 16
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30
Scroll down to find the answer!
Need to refresh your memory before answering this question? Head over to Pathway to review our section on localized esophageal adenocarcinoma and our recent Deep Dive on the topic. |
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Case #2 Conclusion
Answer: D. 16 Explanation:
In 2025, NCCN guidelines updated the recommendation for the minimum recommended number of lymph nodes to be assessed with esophagectomy in upfront surgery patients from 15 to 16. Although 16 is minimum, the updated guidelines also do note that 30 or more is preferred (choice D).
Acknowledgments - Editorial Team: Traci King, MD, Khudhur Moh, MD, Hovhannes Karapetyan, MD
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