Case Of Locally Advanced Esophageal Squamous Cell Carcinoma Anwaar - - PowerPoint PPT Presentation

Case Of Locally Advanced Esophageal Squamous Cell Carcinoma

Anwaar Saeed, MD Assistant Professor, Medical Oncology GI Oncology Program

Clinical Case

• 62 year old male
• Initial presentation of dysphagia, odynophagia, and weight loss
• Imaging: mural thickening of proximal esophagus at the level of the AP window with level 4

mediastinal adenopathy

• EGD/EUS: cT3N1: tumor seen at 20cm

from incisors. Per EUS, tumor was invading through muscularis propria into adventicia. At least 3 peritumoral lymph nodes was seen.

• Esophageal mass biopsy: invasive moderately differentiated squamous cell carcinoma
• ECOG PS 0

What Would You Do?

• A. Concurrent chemoradiotherapy followed by surgery
• B. Definitive dose chemoradiotherapy
• C. Chemotherapy followed by surgery
• D. Definitive dose chemoradiotherapy plus pembrolizumab followed by

adjuvant pembrolizumab

• E. Pembrolizumab

Treatment History

November 2016: Started definitive chemoradiation (CRT) with 5FU plus Cisplatin

Conclusions per Cochrane analysis from 2 trials that compared CRT followed by surgery VS CRT alone:

Addition of esophagectomy:

• Had no significant impact on survival (HR 0.99, 95% CI 0.79-1.24).
• Improved freedom from locoregional relapse (HR 0.55, 95% CI 0.39-0.76)
• Increased the risk of treatment-related mortality (RR 5.11, 95% CI 1.74-15.02)
• Reduced the use of salvage procedures for dysphagia (HR 0.52, 95% CI 0.36-0.75)

Stahl M, et al. Chemoradiation with and without surgery in patients with locally advanced squamous cell carcinoma of the esophagus. J Clin Oncol. 2005;23(10):2310. Bedenne L, et al. Chemoradiation followed by surgery compared with chemoradiation alone in squamous cancer of the esophagus: FFCD 9102. J Clin Oncol. 2007;25(10):1160.

ASCO guidelines

Treatment History – Local & Distant Recurrence

• August 2018:

Imaging with local recurrence and distant metastasis

• ECOG PS 1

Tempus Next Gen Sequencing

PD-L1 CPS: positive, 10% Tumor mutation burden: 12.0 m/MB Microsatellite Instability Status: Stable

What Would You Do Next?

• A. Paclitaxel or Docetaxel
• B. FOLFIRI
• C. Irinotecan
• C. Pembrolizumab
• D. Paclitaxel plus pembrolizumab

Pembrolizumab as 2nd Line Therapy in Esophageal SCC KEYNOTE-181

Manish Shah et al. Pembrolizumab versus chemotherapy as second-line therapy for advanced esophageal cancer: Phase 3 KEYNOTE-181 study. J Clin Oncology 2019 37:15_suppl, 4010-4010

NCCN guidelines – 2nd line treatment

Treatment History

Patient preferred immunotherapy

• September 2018:

Started Pembrolizumab

• Follow up scans in 3 months:

Showed favorable partial response

Treatment History

Patient maintained good partial response

• September 2019:

Stable partial response

• ECOG PS 1
• Tolerating with No immunotherapy related side effects

What Would You Do Next?

• A. Continue pembrolizumab for a total of 2 years then stop if no

disease progression

• B. Continue pembrolizumab until evidence of disease progression
• C. Stop pembrolizumab and resume at time of disease progression
• D. Stop pembrolizumab and consider paclitaxel or FOLFIRI at time
• f disease progression

Treatment History

October 2019: Decided to continue pembrolizumab until disease progression

Questions?