Esophageal Cancer Guidelines

Updated: Apr 10, 2020
  • Author: Muhammad Masab, MD; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
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Guidelines

Guidelines Summary

Guidelines Contributor:  Elwyn C Cabebe, MD Physician Partner, Valley Medical Oncology Consultants; Medical Director of Oncology, Clinical Liason Physician, Cancer Care Committee, Good Samaritan Hospital

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Screening and Surveillance

Recommendations for screening and surveillance of patients with gastroesophageal reflux disease (GERD) and/or Barrett esophagus have been issued by the following organizations:

  • American Society for Gastrointestinal Endoscopy (ASGE)
  • American Gastroenterological Association (AGA)
  • American College of Gastroenterology (ACG)
  • American College of Physicians (ACP)

None of the organizations recommend endoscopic screening of the general population with GERD. There is general agreement among the guidelines that patients with chronic GERD and multiple other risk factors associated with esophageal adenocarcinoma should undergo upper gastrointestinal endoscopy to screen for Barrett esophagus or esophageal adenocarcinoma. [137, 138, 139, 140, 141] Those additional risk factors include the following:

  • Male sex
  • Age 50 years or older
  • White race
  • Hiatal hernia
  • Obesity

The 2015 American Society for Gastrointestinal Endoscopy (ASGE) guideline for the use of endoscopy in the management of GERD recommends consideration of endoscopic screening in select patients with multiple risk factors for Barrett esophagus, but also advises that patients be informed that there is insufficient evidence that this practice prevents cancer or prolongs survival. [141]

The American College of Physicians' (ACP) best practice advice, issued in 2012, offers the following recommendations for upper endoscopy for GERD [140] :

  • Screening endoscopy is not recommended for women of any age or men younger than 50, regardless of other risk factors, because of the low incidence of cancer in these populations.
  • Screening is recommended in both men and women with GERD symptoms despite medical treatment, and especially in those with GERD and dysphagia, bleeding, anemia, weight loss, or recurrent vomiting.
  • No further surveillance is recommended if endoscopy shows negative results for Barrett esophagus.
  • In patients with Barrett esophagus and no dysplasia, surveillance examinations should occur at intervals of 3 to 5 years; shorter intervals are indicated in patients with Barrett esophagus and dysplasia.

The American College of Gastroenterology (ACG) guidelines for the surveillance and therapy of Barrett esophagus [139] are listed in the table below.

Table 6. ACG Recommendations on surveillance of Barrett esophagus (Open Table in a new window)

Biopsy Finding  Recommended Surveillance/Intervention
Barrett Esophagus (BE) without dysplasia Endoscopic surveillance every 3 years for patients with BE without dysplasia on 2 consecutive endoscopies with biopsies within a year. 
BE with low-grade dysplasia (LGD) For patients with confirmed low-grade dysplasia and without life-limiting comorbidity, endoscopic therapy is considered as the preferred treatment modality, although endoscopic surveillance is an acceptable alternative (Endoscopy within 6 months is warranted to ensure that no HGD is present in the esophagus. Follow-up endoscopy is recommended annually until no dysplasia is detected on 2 consecutive endoscopies with biopsies.)
BE with high- grade dysplasia (HGD) Patients with confirmed high-grade dysplasia should be managed with endoscopic therapy. In case of life-limiting comorbidity endoscopy within 3 months is recommended to rule out adenocarcinoma of the esophagus. Follow-up endoscopy every 3 months is recommended thereafter. 

 

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Evaluation and Staging

Society of Thoracic Surgeons

In 2013, the Society of Thoracic Surgeons released clinical practice guidelines to assist in the diagnosis and treatment of localized esophageal cancer. Their recommendations include the following [67] :

  • For the diagnosis of esophageal cancer, flexible endoscopy with biopsy is the primary method

  • For early-stage esophageal cancer, CT of the chest and abdomen is an optional test for staging; for locoregionalized esophageal cancer, CT of the chest and abdomen is a recommended test for staging

  • For early-stage esophageal cancer, PET is an optional test for staging. For locoregionalized esophageal cancer, PET is a recommended test for staging

  • In patients without metastatic disease, endoscopic ultrasonography is recommended to improve the accuracy of staging

  • In patients with small, discrete nodules or areas of dysplasia in whom disease appears limited to the mucosa or submucosa as assessed by endoscopic ultrasonography, endoscopic mucosal resection should be considered as a diagnostic/staging tool

  • In patients with locally advanced (T3/T4) adenocarcinoma of the esophagogastric junction infiltrating the anatomic cardia or Siewart type III esophagogastric tumors, laparoscopy is recommended to improve accuracy of staging.

European Society for Medical Oncology (ESMO)

The ESMO guidelines include the following key recommendations for diagnosis and staging [144] :

  • All patients with new dysphagia, gastrointestinal bleeding, recurrent aspiration or emesis, weight loss, and/or loss of appetite should undergo upper gastrointestinal endoscopy
  • Immunohistochemical stainings should be used to differentiate between squamous cell carcinoma (SCC) and adenocarcinoma 
  • Staging should include a complete clinical examination and a CT scan of the neck, chest and abdomen
  • In candidates for surgical resection, endoscopic ultrasound (EUS) is performed to evaluate the T and N staging
  • In candidates for esophagectomy, F0FDG-PET should be performed 

National Comprehensive Cancer Network (NCCN)

The NCCN guidelines include the following recommendations regarding diagnostic endoscopy [83] :

  • Endoscopy should be used to determine the presence and location of esophageal cancer and to biopsy any suspicious lesions.
  • Six to eight biopsies should be performed for histologic analysis; cytologic brushings and washings are not adequate for initial diagnosis. 
  • Endoscopic resection (ER) of focal nodules should be performed for assessment of early-stage disease; ER may be fully therapeutic if the entire lesion can be removed.
  • In patients who are unable to undergo biopsy, a 'liquid biopsy' using an next-generation sequencing (NGS)–based comprehensive genomic profiling assay may be considered.

The 2013 American Society for Gastrointestinal Endoscopy (ASGE) guidelines for use of endoscopy in the assessment and treatment of esophageal cancer make the following recommendations for accurate staging [142] :

  • Endoscopic ultrasound (EUS) and fine needle aspiration (FNA), when indicated, in conjunction with cross-sectional imaging is preferred over CT
  • Endoscopic mucosal or submucosal dissection is indicated for the treatment and staging of nodular Barrett esophagus and suspected squamous cell carcinoma and adenocarcinoma

Pathological Testing

Guidelines from the College of American Pathologists, American Society for Clinical Pathology, and American Society of Clinical Oncology, issued in 2016, include the following recommendations for clinicians [143] :

  • Request HER2 testing on tumor tissue in patients with advanced esophageal adenocarcinoma who are potential candidates for HER2-targeted therapy.
  • Request HER2 testing on tumor tissue in the biopsy or resection specimens (primary or metastasis), preferably before starting trastuzumab therapy, if such specimens are available and adequate; an acceptable alternative is HER2 testing on fine-needle aspiration specimens.

NCCN guidelines for workup include the following recommendations [83] :

  • HER2 testing is recommended for patients with inoperable adenocarcinoma esophageal or esophagogastric junction (EGJ) cancer considering treatment with trastuzumab.

  • Testing for high microsatellite instability (MSI-H), deficient mismatch repair (dMMR), and programmed death ligand 1 (PD-L1)\ is recommended in all patients with esophageal or EGJ cancer who are candidates for treatment with PD-1 inhibitors.

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Management of Adenocarcinoma

National Comprehensive Cancer Network

National Comprehensive Cancer Network (NCCN) treatment recommendations for adenocarcinomas in medically fit patients include the following [83] :

  • Stage Tis (in situ) or T1a:  The preferred treatments are endoscopic resection (ER), ablation or ER followed by ablation.  Esophagectomy is an alternative treatment option.
  • Superficial T1b tumors: Treated by ER followed by ablation or esophagectomy.
  • Stage T1b, N0 and T2, N0 (low-risk): Treated by esophagectomy. 
  • Stage T1b,N+, T2, N0 (high-risk), T2N+ or T3-T4a, any N:  Preoperative chemoradiation is a category 1–preferred recommendation. Other options include definitive chemoradiation (for patients who refuse surgery), and perioperative or preoperative chemotherapy with esophagectomy.
  • Stage T4b (unresectable) tumors: Definitive chemoradiation is the preferred treatment modality. Chemotherapy alone may be considered in patients with involvement of the trachea, great vessels, or heart.

For patients with adenocarcinoma who have not received preoperative therapy, no further treatment is necessary (irrespective of their nodal status) if there is no residual disease at surgical margins (R0 resection). Patients with microscopic (R1 resection) or macroscopic (R2 resection) residual disease should be treated with fluoropyrimidine-based chemoradiation. Palliative therapy is an alternative option for patients with macroscopic residual disease. [83]

Postoperative treatment is based on the surgical margins, nodal status, and histology, as follows [83] :

  • For patients with adenocarcinoma who have not received preoperative therapy, no further treatment is necessary for patients with Tis and T1, N0 tumors, if there is no residual disease at surgical margins (R0 resection)
  • Postoperative fluoropyrimidine-based chemoradiation (following R0 resection) should be considered for patients with T2, N0 tumors.
  • Chemoradiation is recommended for all patients with T3-T4 tumors  and node-positive T1-T2 tumors following R0 resection.
  • Chemotherapy is an alternative postoperative treatment for all patients with R0 resction of node positive tumors.
  • Patients with microscopic (R1 resection) or macroscopic residual disease with no distant metastatic disease (R2 resection) should be treated with fluoropyrimidine-based chemoradiation.
  • Palliative therapy is an alternative option for patients with macroscopic residual disease.

NCCN guidelines for the management of adenocarcinomas in patients who are not surgical candidates includes the following [83] :

  • Stage Tis (in situ):  The preferred treatments are ER, ablation, or ER followed by ablation
  • Stage T1a and Stage T1b, N0:  ER or ER followed by ablation
  • Stage T1b,N+, T2-T4a, any N and T4b (unresectable) tumors:  Definitive chemoradiation is the preferred treatment.  For patients unable to tolerate chemoradiation, palliative radiation therapy (RT) or best supportive palliative care is given.

NCCN recommendations for first-line systemic therapy of advanced or metastatic disease are as follows [83] :

  • First-line systemic therapy regimens with 2 cytotoxic drugs are preferred for treatment of advanced disease because of their lower toxicity.
  • Three-drug cytotoxic regimens should be reserved for medically fit patients with good performance status and access to frequent toxicity evaluation.
  • The preferred regimens for first-line systemic therapy include a fluoropyrimidine (fluorouracil or capecitabine) combined with either oxaliplatin (preferred) or cisplatin.
  • Patients with suspected stage IV metastatic adenocarcinoma should undergo assessment for tumor HER2 overexpression; in those with HER2-positive metastatic adenocarcinoma, trastuzumab should be added to first-line chemotherapy (category 1 for combination with cisplatin and fluoropyrimidine).

NCCN recommendations for second-line and subsequent systemic therapy of advanced or metastatic disease are as follows [83] :

  • The selection of regimens for second-line or subsequent therapy depends on prior therapy and performance status.
  • Category 1 preferred options for second-line or subsequent therapy include ramucirumab and paclitaxel and trifluridine and tipiracil for EGJ adenocarcinoma, single-agent docetaxel, paclitaxel, and irinotecan.
  • Pembrolizumab is a third-line or subsequent therapy option for esophageal and EGJ adenocarcinomas with PD-L1 expression levels by combined positive score (CPS) of ≥1.
  • Other recommended combined regimens for second-line therapy for esophageal adenocarcinoma include ramucirumab and paclitaxel,  irinotecan and cisplatin, and irinotecan and docetaxel (category 2B).

European Society for Medical Oncology 

European Society for Medical Oncology (ESMO) guidelines for local and regional disease include the following [144] :

  • Surgery is the treatment of choice for patients with stage T1-T2, N0 tumors. 
  • Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are the preferred resection techniques for stage T1a and are considered an alternative to esophagectomy.  
  • Radical and transthoracic esophagectomy is preferred for T1b-T2, N0 tumors.
  • For non-surgical candidates, chemoradiation therapy is preferred over RT alone. [144]

For locally advanced disease (T3–T4), surgery alone is not standard of care and preoperative treatment is indicated. Perioperative chemotherapy with regimens containing a platinum and a fluoropyrimidine for a duration of 8–9 weeks in the preoperative phase (as well as 8–9 weeks in the postoperative phase, if feasible) or preoperative chemoradiotherapy (41.4–50.5 Gy) is the standard of care. [144]

Patients with metastatic disease should be offered palliative treatment specific to their clinical situation. [144]

American College of Gastroenterology 

American College of Gastroenterology (ACG) recommendations regarding endoscopic treatment include the following [139] :

  • In patients with T1a esophageal adenocarcinoma, endoscopic therapy is the preferred therapeutic approach (strong recommendation, moderate level of evidence)
  • In patients with T1b esophageal adenocarcinoma, consultation with multidisciplinary surgical oncology team should occur before embarking on endoscopic therapy; in such patients, endoscopic therapy may be an alternative strategy to esophagectomy, especially in those with superficial (sm1) disease with a well-differentiated neoplasm lacking lymphovascular invasion, as well as those who are poor surgical candidates (strong recommendation, low level of evidence)
  • In patients with known T1b disease, EUS may have a role in assessing and sampling regional lymph nodes, given the increased prevalence of lymph node involvement in these patients compared with less advanced disease (strong recommendation, moderate level of evidence)

Society of Thoracic Surgeons

In 2014, the Society of Thoracic Surgeons (STS) released clinical practice guidelines for multimodal treatment of esophageal cancer with the following recommendations [145] :

  • Locally advanced disease should be treated in a multidisciplinary setting
  • Restaging should be performed after neoadjuvant therapy and before surgery
  • Endoscopic ultrasound restaging for residual local disease is inaccurate and can be omitted
  • A PET scan should be used for restaging after neoadjuvant therapy to detect interval development of distant metastatic disease
  • Either neoadjuvant chemotherapy or chemoradiation therapy for locally advanced adenocarcinoma; multimodality therapy has advantages over surgical resection alone
  • For patients with adenocarcinoma who have not received neoadjuvant therapy, adjuvant chemoradiotherapy is an option for regional lymph node disease.
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Management of Squamous Cell Carcinoma

National Comprehensive Cancer Network

The NCCN recommends consideration of enteric feeding tube placement for preoperative nutritional support of patients with squamous cell carcinoma (SCC). For treatment of medically fit patients, NCCN recommendations include the following [83] :

  • Stage Tis (in situ):  The preferred treatments are endoscopic resection (ER), ablation, or ER followed by ablation.  Esophagectomy is an alternative treatment option.
  • Stage T1a: The preferred treatments are endoscopic resection (ER), ablation or ER followed by ablation. Esophagectomy is an alternative treatment option.
  • Stage T1b, N0 and T2, N0 (low-risk): Esophagectomy. 
  • Stage T1b,N+, T2, N0 (high-risk), T2N+ or T3-T4a, any N:  Preoperative chemoradiation for SCC of the non-cervical esophagus or definitive chemoradiation for SCC of the cervical esophagus
  • Stage T4b tumors: Definitive chemoradiation is the preferred treatment modality. Chemotherapy alone may be considered in patients with involvement of the trachea, great vessels, or heart.

Postoperative treatment of SCC is based on the surgical margins, nodal status, and histology, as follows [83] :

  • For patients who have not received preoperative therapy, no further treatment is necessary (irrespective of their nodal status) if there is no residual disease at surgical margins (R0 resection).
  • Patients with microscopic (R1 resection) or macroscopic (R2 resection) residual disease should be treated with fluoropyrimidine-based chemoradiation.
  • Palliative therapy is an alternative option for patients with macroscopic residual disease.

NCCN guidelines for the management of SCC in patients who are not surgical candidates includes the following [83] :

  • Stage Tis (in situ):  The primary treatments are ER, ablation or ER followed by ablation
  • Stage T1a and Stage T1b, N0:  Treated by ER or ER followed by ablation
  • Stage T1b,N+, T2-T4a, any N and T4b (unresectable) tumors:  Definitive chemoradiation is the preferred treatment.  For patients unable to tolerate chemoradiation, palliative radiation therapy (RT) or best supportive palliative care is given.

NCCN recommendations for first-line systemic therapy of advanced or metastatic disease are as follows [83] :

  • First-line systemic therapy regimens with 2 cytotoxic drugs are preferred for treatment of advanced disease because of their lower toxicity.
  • Three-drug cytotoxic regimens should be reserved for medically fit patients with good performance status and access to frequent evaluation of toxicity.
  • The preferred regimens for first-line systemic therapy include a fluoropyrimidine (fluorouracil or capecitabine) combined with either oxaliplatin (preferred) or cisplatin.

NCCN recommendations for second-line and subsequent systemic therapy of advanced or metastatic disease are as follows [83] :

  • The selection of regimens for second-line or subsequent therapy depends on prior therapy and performance status.
  • Category 1 preferred options for second-line or subsequent therapy include single-agent docetaxel, paclitaxel, and irinotecan.
  • Pembrolizumab is a category 1 option for SCC with PD-L1 expression levels (by combined positive score [CPS]) of ≥10  
  • Other recommended combined regimens for second-line therapy include irinotecan and cisplatin, and irinotecan and docetaxel (category 2B).

European Society for Medical Oncology 

ESMO guidelines recommend surgery as the treatment of choice for patients with stage T1-T2, N0 tumors. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are the preferred resection techniques for stage T1a and are considered as an alternative to esophagectomy.  Radical and transthoracic esophagectomy is preferred for T1b-T2, N0 tumors. For non-surgical candidates, chemoradiation therapy is preferred over RT alone. [144]

For locally advanced disease (T3–T4), surgery alone is not standard of care and preoperative treatment is indicated. The guidelines note that while SCC patients benefit from preoperative chemotherapy, preoperative chemoradiation therapy results in higher rates of complete tumor resection and better local tumor control and survival. Weekly administration of carboplatin (area under the curve of 2 mg/ml/min) and paclitaxel (50 mg/m2) for 5 weeks and concurrent RT (41.4 Gy in 23 fractions, 5 days/week), followed by surgery is considered standard of care. [144]

Patients with metastatic disease should be offered palliative treatment specific to their clinical situation. [144]

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Surveillance

The ESMO guidelines note that there is no evidence that regular follow-up after initial therapy has an impact on survival outcomes. Therefore, follow-up visits should concentrate on symptoms, nutrition and psychosocial support. However, in patients with a complete response to CRT and no operation, a 3-month follow-up based on endoscopy, biopsies and CT scan may detect early recurrence. [144]

According to NCCN guidelines, surveillance strategies after successful local therapy of esophageal cancers remain controversial since very limited prospective data are available on effective surveillance strategies. Recommendations for surveillance are based on the available evidence from retrospective studies and the expertise of the panel members. [83]

For asymptomatic patients, NCCN recommends that follow-up include a complete history and physical examination every 3 to 6 months for 1 to 2 years, then every 6 to 12 months for 3 to 5 years, and annually thereafter. Complete blood cell count, comprehensive serum chemistry evaluation, upper GI endoscopy with biopsy, and imaging studies should be obtained as clinically indicated. In addition, some patients may require dilatation of an anastomotic or a chemoradiation-induced stricture. Nutritional assessment and counseling should be performed. [83]

NCCN surveillance reommendations by disease stage are listed below. [83]

Stage Tis or T1a without Barrett esophagus (BE): Following endoscopic resection (ER)/ablation, upper GI endoscopy (EGD) every 3 months for the first year, then every 6 months for the second year, and annually thereafter.  Imaging studies for surveillance are not recommended.

Stage Tis or T1a: Following esophagectomy, incompletely resected BE should undergo ablation. EGD every 3 months for the first year, then every 6 months for the second year, and annually thereafter. Imaging studies for surveillance are not recommended.

Stage pT1b (N0 on endoscopic ultrasound [EUS])Following endoscopic resection (ER)/ablation, esophagogastroduodenoscopy (EGD) every 3 months for the first year, then every 4-6 months for the second year, and annually thereafter.  EUS may be considered.  CT with contrast may be considered every 12 months for 3 years and then as clinically indicated.

Stage T1b, Any N: Following esophagectomy, CT with contrast should be considered every 12 months for 3 years if additional curative-intent therapy for recurrence is likely.

Following chemoradiation, EGD every 3-6 months for 2 years, then annually for 3 more years thereafter. CT with contrast should be considered every 6-9 months for 2 years and annually for up to 5 years thereafter. Patients who are candidates for salvage esophagectomy, EUS/fine needle aspiration (FNA) as indicated based on imaging results.

Stage II-III (T2-T4, N0-N+, T4b): Following chemoradiation, CT with contrast should be considered every 6 months for up to 2 years if additional curative-intent therapy for recurrence is likely.  EGD every 3-6 months for 2 years, then every 6 months for 1 more year, then as clinically indicated.  Unscheduled evaluation should be performed in symptomatic patients. 

Following trimodal therapy, CT with contrast should be considered every 6 months for up to 2 years if additional curative-intent therapy for recurrence is likely. Unscheduled evaluation should be performed in symptomatic patients. EGD should be performed as clinically indicated.

The value of carcinoembryonic antigen (CEA) and other tumor markers is unknown.

 

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Palliative Care

NCCN guidelines recommend the following for palliative/best supportive care [83] :

  • Palliative care is indicated for medically unfit patients, or those with unresectable or metastatic recurrence.
  • Patients with complete esophageal obstruction can be treated with endoscopic lumen restoration, external beam radiation therapy (EBRT), chemotherapy, or surgery.
  • Surgical or radiologic placement of jejunostomy or gastronomy tubes may be necessary to provide adequate hydration and nutrition, if endoscopic lumen restoration is not undertaken or is unsuccessful.
  • Brachytherapy may be considered instead of EBRT, if lumen can be restored using appropriate applicators.
  • For patients with severe esophageal obstruction (those able to swallow liquids only), some additional options include endoscopic lumen enhancement (wire-guided or balloon dilation) and endoscopy or fluoroscopy-guided placement of covered expandable metal stents. 

The 2013 American Society for Gastrointestinal Endoscopy (ASGE) guidelines have the following recommendations for palliative care [142] :

  • Esophageal stent placement is the preferred method for palliation of dysphagia and fistulae.
  • Patient preferences, quality of life, and prognosis should be addressed with the patient and family before initiating endoscopic palliation.
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COVID-19

The American College of Surgeons has released a guideline on COVID-19–related triage of patients with thoracic cancer. [146]   As a general recommendation, the guideline recommends that determination of case status (ie, risk of death time frame) be made by Division, ideally in a multi-clinician setting (case review conference).

Suggested consent language: You are being offered surgery now, because at this time we feel that your risk of being harmed by infections, including coronavirus, within the hospital is low, and that delaying surgery could reduce your chances of being cured of cancer.  It is not possible to know either the risk of delaying surgery or the chance of getting an infection with perfect accuracy, but I did consult my colleagues and it is our group’s opinion that surgery is a reasonable thing to do.

Specific guideline recommendations are divided into three phases, depending on the COVID-19 status at a given hospital.

Phase I  – Semi-urgent Setting (Preparation Phase)

Features of this phase are as follows:

  • The hospital has few COVID-19 patients
  • Resources are not exhausted
  • ICU ventilator capacity exists
  • The COVID-19 trajectory is not in rapid escalation phase

In phase I, surgery should be restricted to patients whose survival is likely to be compromised if surgery not performed within next 3 months. The following cases need to be done as soon as feasible (recognizing that the status of each hospital is likely to evolve over next week or two):

  • Esophageal cancer T1b or greater
  • Stenting for obstructing esophageal tumor
  • Patients enrolled in therapeutic clinical trials

Cases that should be deferred include the following:

  • Patients unlikely to separate from mechanical ventilation or likely to have prolonged ICU needs (ie, particularly high-risk patients)
  • Upper endoscopy

The following alternative treatment approaches can be considered (assuming resources permit):

  • Early-stage esophageal cancer (stage T1a/b superficial) managed endoscopically
  • If the patient is eligible for adjuvant therapy, neoadjuvant therapy
  • Stereotactic ablative radiotherapy (SABR)
  • Ablation (eg, cryotherapy, radiofrequency ablation)
  • Stent for obstructing cancers, then treat with chemoradiation
  • Follow patients after their neoadjuvant therapy for “local only failure” (ie, salvage surgery)
  • Extending chemotherapy (additional cycles) for patients completing a planned neoadjuvant course

Phase II  –   Urgent Setting

Features of this phase are as follows:

  • Many COVID 19 patients
  • ICU and ventilator capacity limited
  • OR supplies limited or
  • COVID trajectory within hospital in rapidly escalating phase

Surgery should be restricted to patients whose survival is likely to be compromised if surgery is not performed within the next few days. Cases that need to be done as soon as feasible (recognizing that the hospital’s status is likely to progress over next few days):

  • Perforated cancer of esophagus – not septic
  • Management of surgical complications in a hemodynamically stable patient

All thoracic procedures typically scheduled as routine/elective (ie, not add-ons) should be deferred.

Alternative treatment approaches that are recommended, assuming resources permit, are as follows:

  • Transfer patient to a hospital that is in Phase I
  • If the patient is eligible for adjuvant therapy, give neoadjuvant therapy
  • SABR
  • Ablation (eg, cryotherapy, radiofrequency ablation)
  • Reconsider neoadjuvant therapy as definitive chemoradiation therapy, and follow patients for “local only failure” (ie, salvage surgery)

Phase III

In this phase, hospital resources are all routed to COVID-19 patients, the hospital has no ventilator or ICU capacity, and OR supplies are exhausted. Surgery should be restricted to patients whose survival is likely to be compromised if surgery is not performed within next few hours.

Cases that need to be done as soon as feasible (status of hospital likely to progress in hours) are as follows:

  • Perforated cancer of esophagus – septic patient
  • Management of surgical complications – unstable patient (active bleeding not amenable to nonsurgical management, anastomotic leak with sepsis)

All other cases should be deferred. Recommended alternative treatments are the same as for Phase II.

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