Carcinoma de esofago.1
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Dr. Luis Miguel Zetina ToacheOncología Medica
Cáncer Consultants GT
Cáncer de esófago
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QUE LE SUGIERO A MI PACIENTE: ???
Lo opero ??? No lo opero ??? LE Pido TAC, PET O US TE ??? Lo mando a radioterapia ??? Le sugiero Quimio ??? O mejor RT/QT ??? Y después lo opero ???
Vale la pena????
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Carcinoma de Esofago(Epidemiologia)
Carcinoma de Esofago(Epidemiologia)
11 millones de casos cancer CANCER G.I Predomina (1/3)
GASTRICO, COLON- RECTO HEPATICO
ESOFAGICO: 8 causa de cáncer a nivel mundial
480,000 casos nuevos 400,000 muertes. Mortalidad 80% Epidermoide mas frecuente Adenocarcinoma UGE > 70%
en USA
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GLOBOCAN 2008
International Agency for Research on Cancer GUATEMALA C.A.
+ Incidencia ?
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Pohl H , Welch H G JNCI J Natl Cancer Inst 2005;97:142-146
© Oxford University Press
AdenoCa
Esófago
Melanoma
Próstata
Mama
Pulmón
Colon-recto
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Pohl H , Welch H G JNCI J Natl Cancer Inst 2005;97:142-146
© Oxford University Press
Epidermoide
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Pohl H , Welch H G JNCI J Natl Cancer Inst 2005;97:142-146
© Oxford University Press
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Pohl H , Welch H G JNCI J Natl Cancer Inst 2005;97:142-146
© Oxford University Press
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Pohl H , Welch H G JNCI J Natl Cancer Inst 2005;97:142-146
© Oxford University Press
AVANZADA
LOCO REGIONAL
LOCALIZADA
IN SITU
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Pohl H , Welch H G JNCI J Natl Cancer Inst 2005;97:142-146
© Oxford University Press
INCIDENCIA
MORTALIDAD
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PAPEL DEL ONCOLOGO CLINICO(equipo multidisciplinario)
Es neoplasia Gástrica o EsofágicaAbordaje para Estadificación: TAC - PET-
US Etapa Clínica: TNMDeterminación de marcadores IHQ: (HER-2)Quimioterapia: Neo Adyuvante
Adyuvante
Concomitante
Paliativa
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PAPEL DEL ONCOLOGO CLINICO(equipo multidisciplinario)
Es neoplasia Gástrica o EsofágicaAbordaje para Estadificación: TAC –PET- US
TEEtapa Clínica: TNMDeterminación de marcadores IHQ (HER-2)Quimioterapia: Adyuvante
Neo adyuvante
Concomitante
Paliativa
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Carcinoma de Unión GEDatos epidemiológicos, clínicos, diagnósticos y
terapéuticos AMBIGUOS. Entre Ca. Gástrico y Esofágico UGE
Cáncer GASTRICO ( > 50% UgE )Cáncer ESOFAGICO ( > 50% UgE)
Factores riesgo: Helicobacter Pilori (gástrico)
Esófago de Barrett (esófago)
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PAPEL DEL ONCOLOGO CLINICO(equipo multidisciplinario)
Es neoplasia Gástrica o Esofágica
Abordaje para Estadificación: TAC – PET- US TE
Etapa Clínica: TNMDeterminación de marcadores IHQ (HER-2)Quimioterapia: Adyuvante
Neo adyuvante
Concomitante
Paliativa
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Figure 1a. T4 adenocarcinoma of the midesophagus with invasion into the thoracic aorta.
Bruzzi J F et al. Radiographics 2007;27:1635-1652
©2007 by Radiological Society of North America
N
T
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diagnostico
seguimiento
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PAPEL DEL ONCOLOGO CLINICO(equipo multidisciplinario)
Es neoplasia Gástrica o EsofágicaAbordaje para Estadificación: TAC –PET- US
TEEtapa Clínica: TNM
Determinación de marcadores IHQ (HER-2)
Quimioterapia: Adyuvante
Neo adyuvante
Concomitante
Paliativa
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Her-2 Ca. Gastrico y Union GE
ToGA
Herceptin QT
QT
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PAPEL DEL ONCOLOGO CLINICO(equipo multidisciplinario)
Es neoplasia Gástrica o EsofágicaAbordaje para Estadificación: TAC –PET- US
TEEtapa Clínica: TNMDeterminación de marcadores IHQ (HER-2)
Quimioterapia: Neo Adyuvante Adyuvante Concomitante Paliativa
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Cancer de EsofagoTratamiento MedicoCancer de EsofagoTratamiento Medico
ADYUVANTE : TODO TRATAMIENTO ADMINISTRADO POSTERIOR A CIRUGIA EN BUSCA DE AUMENTAR SOBREVIDA GLOBAL Y SOBREVIDA LIBRE DE RECAIDA
NEO ADYUVANTE: TODO TRATAMIENTO ADMINISTRADO PREVIO A CIRUGIA PARA AUMENTAR TASA DE CIRUGIA RO, MEJOR RESPUESTA, SVG Y SLR. (DA LA OPORTUNIDAD DE EVALUAR RESPUESTA AL TX)
CONCOMITANTE: EFECTO SINERGISTICO CON RT
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EL PORQUE DEL TRATAMIENTO Neoadjuvante/Adjuvante/ConcomitanteEL PORQUE DEL TRATAMIENTO Neoadjuvante/Adjuvante/Concomitante
Ventajas En la mayoria de los casos el cancer de esofago YA
es una enfermedad sistemica al diagnostico.La cirugia sola es curativa solo en por pequeño grupo
de pacientes.El patron de recurrencia presenta recaida local y
sistemica.Desventajas: Solo un 50 % de pacientes responde a tratamientoRetrasa la cirugiaPosibilidad de seleccionar clonas resistentes a drogas
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Adyuvante: RT vrs QT QT vrs RT vrs QT/RT NO TRATAMIENTO
ADYUVANTE
Neo Adyuvante: RT vrs QT QT vrs RT vrs QT/RT NO TRATAMIENTO NEO ADY
Concomitante: QT + RT
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Estudio comparativoQt vrs Cirugia sola
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Estudio MAGIC
QUIMIO VRS CIRUGIA
N Engl J Med 2006; 355:11-20July 6, 2006 ...
SLP: P= 0.001
SG: P= 0.009
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224 ptes. ( ADENOCARCINOMA esófago/estomago)
11% Esofago64% UGE25% Gástrico
QUIMIO: CIS- 5FU X 3 CICLOS
31% MEJORIA
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4.48a
1.79 aP=0.002
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(Chemo Radiotherapy Oesophageal cancer followed Surgical Study
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Walsh et al
Kaplan–Meier Plot of Survival of Patients with Esophageal Adenocarcinoma, According to the Intention-to-Treat Analysis.
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RT NEO NO INDICADART NEO NO INDICADA
RT/QT MEJOR QUE RT
QT NEO MEJOR C SOLA?
QT NEO MEJOR EN ADENO
META ANALISIS Cochrane 2008
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Guidelines for the Management of Oesophageal and Gastric Cancer
William H Allum; Jane M Blazeby; S Michael Griffin; David Cunningham; Janusz A Jankowski; Rachel Wong
Gut. 2011;60(11):1449-1472 |© 2011 BMJ Publishing Group Ltd and British Society of Gastroenterology
http://www.medscape.com/oncology
Posted: 10/25/2011
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Guidelines. Esophageal Cancer Gut. 2011;60(11):1449-1472
RT neo adyuvante:
Metaanalisis RT pre operatorio ptes con Ca. esofago resecable ( cualquier histologia), mejoria en 3-4% en SVG. (HR: 0.89, 95% CI, p=0.062
QT neoadyuvante: Trial 0E02 (802 ptes) QT vrs S. p= 0.004 (sva 2ª. 43%-34%) . Trial IS IG 0-113 no confirmatorio. Metaanalisis reciente confirman beneficio de QT pre op. Vrs S sola (HR 0.78. p=0.014)
RT PRE OP NO INDICADA RT PRE OP NO INDICADA
QT NEO ADYUVANTE STANDARD OF CAREPTE CON ADENOCARCINOMA ESO Y UGE
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Guidelines. Esophageal Cancer Gut. 2011;60(11):1449-1472
QT ADYUVANTE NO ESTA INDICADA EN PACIENTES CON CANCER DE ESOFAGO
META ANALISIS DE 1001 PTES EN 6 ESTUDIOS NO MOSTRO MEJORIA EN SOBREVIDA
LA MAYORIA DE ESTUDIOS CON SCC
Ychou M, Boige V, Pignon J-P, et al. Perioperative chemotherapy compared with surgery alone for resectable gastroesophageal adenocarcinoma: an FNCLCC and FFCD multicenter phase III trial. J Clin Oncol 2011;29:1751–21.
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N Engl J Med 2012;366:2074-84.Copyright © 2012 Massachusetts Medical Society.
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N Engl J Med 2012;366:2074-84.Copyright © 2012 Massachusetts Medical Society.
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Characteristics of Patients with Resectable Esophageal or Esophagogastric-Junction Cancer, According to Treatment Group.
van Hagen P et al. N Engl J Med 2012;366:2074-2084.
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Kaplan–Meier Plots of Estimated Overall 5-Year Survival.
van Hagen P et al. N Engl J Med 2012;366:2074-2084.
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Adverse Events during Neoadjuvant Chemoradiotherapy and after Surgery.
van Hagen P et al. N Engl J Med 2012;366:2074-2084.
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CANCER DE ESOFAGO(CONCLUSIONES
Aumento marcado en casos de Cáncer de esófagoAumento sobre todo en tipo Adenocarcinoma
(obesidad, reflujo GE, esófago de Barrett)Estadificación sumamente importante (PET, USE,
BAAF)Identificar localización de neoplasia para definir TXMejor opción terapéutica en Enf. Localmente
avanzada RT/QT concomitante seguida de CirugíaSI enfermedad avanzada: paliación por obstrucción
y Quimioterapia.
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CANCER DE ESOFAGO(CONCLUSIONES ( S, RT, QT, RT/QT)Algo mejor que Cirugía debería ofrecérsele al
pte. T3 o N+Adenocarcinoma Esofágico: (AC)o QT pre op. Mejora la Sobrevida y es Factibleo RT/QT Mejora OS y mas Resp. Completaso Mayor toxicidad Carcinoma Epidermoide Esofágico: (SCC)o QT pre Op. Beneficio ?o RT/QT : Tratamiento primario Aceptable
Mejora Control local pero no SG
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gracias