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 2 nd 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 – 2 nd 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 of disease progression
Treatment History October 2019: Decided to continue pembrolizumab until disease progression
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