Esophageal Cancer Medical Slides

Present the CROSS trial (2012, NEJM): 368 patients with resectable esophageal/GEJ cancer randomized to neoadjuvant chemoradiation (carboplatin AUC2 + paclitaxel 50 mg/m² weekly × 5 + 41.4 Gy in 23 fractions) followed by surgery versus surgery alone. Results: R0 resection rate 92% vs 69%, pathologic complete response 29%, median OS 49 vs 24 months. 10-year follow-up (2021): OS 38% vs 25%, benefit sustained across histologies but more pronounced in squamous cell carcinoma (10-year OS 46% vs 23%) than adenocarcinoma (36% vs 27%). This established neoadjuvant chemoradiation as standard for cT1b-T3/N0-3/M0 esophageal cancer.

Present the three approaches: Ivor Lewis (transthoracic — right thoracotomy + laparotomy): preferred for distal esophageal/GEJ tumors, allows formal thoracic lymphadenectomy, intrathoracic anastomosis (leak rate 5-15%). McKeown (three-field — right thoracotomy + laparotomy + cervical anastomosis): for mid/upper esophageal tumors, cervical anastomosis is safer if leaks occur (drains externally, lower mediastinitis risk), but higher stricture and recurrent laryngeal nerve injury rates. Transhiatal (no thoracotomy): avoids thoracotomy morbidity, cervical anastomosis, but limited mediastinal lymphadenectomy. MIRO trial: hybrid MIE (laparoscopic abdomen + open thoracotomy) reduced pulmonary complications vs open. TIME trial: fully MIE reduced in-hospital pulmonary infections (12% vs 34%).

Present CheckMate 577 (2021, NEJM): patients with esophageal/GEJ cancer who had neoadjuvant chemoradiation + surgery but did NOT achieve pathologic complete response (i.e., residual disease, ypT1-4 or ypN+) randomized to nivolumab 240 mg q2w × 16 weeks then 480 mg q4w (total 1 year) versus placebo. Disease-free survival doubled: median 22.4 months vs 11.0 months (HR 0.69). Benefit seen in both adenocarcinoma and squamous cell carcinoma, regardless of PD-L1 status. This established adjuvant nivolumab as standard of care for the 70-75% of CROSS-treated patients who do not achieve pCR. Monitor for immune-related adverse events (colitis, pneumonitis, hepatitis, thyroiditis).