Locally Advanced Distal Esophageal Adenocarcinoma: Neoadjuvant CROSS Therapy and Robotic Ivor-Lewis Esophagectomy

19 Oct 2021 02:10 02:10
Mainz
Peter Grimminger Host

Patient Profile & Clinical Presentation

  • Patient: 52-year-old man

  • Diagnosis: Locally advanced adenocarcinoma of the distal esophagus.

  • Clinical Presentation: Two-month history of abdominal pain associated with symptoms of gastro-esophageal reflux.

  • Dysphagia: Absence of dysphagia.

Diagnostic Workup

Upper Gastrointestinal Endoscopy

  • Findings: Exophytic and ulcerated tumor, not stenosing, extending from 27 cm to 35 cm from the upper incisors and occupying 2/3 of the circumference.

  • Biopsy: Poorly differentiated adenocarcinoma.

Ultrasound-Endoscopy Staging

  • Staging: uT3 uN+ (peritumor lymph nodes).

Thoraco-Abdominal Computed Tomography (CT Scan)

  • Distal esophagus tumor with peritumor lymph nodes.

  • No distant metastasis.

PET-CT

  • Positive FDG uptake.

  • Distal esophageal carcinoma with no evidence of distant metastasis.

Tumor Markers

  • CA 19-9: 7.2 U/ml

  • CEA: 2.0 U/ml

Clinical Staging

uT3uN+cM0

Neoadjuvant Treatment

Discussion at Tumor Board, with indication of neoadjuvant therapy.

  • Regimen: CROSS regimen from 18.01.2021 to 17.02.2021 (36/41.4 Gy).

  • Tolerance: Radiotherapy was not well tolerated due to progressive radio-induced esophagitis.

  • Nutritional Support: The patient therefore required home parenteral nutrition.

Restaging

Upper Gastrointestinal Endoscopy

  • Not stenosing exophytic tumor, in partial regression.

Thoraco-Abdominal Computed Tomography (CT Scan)

  • Regression of the esophageal parietal thickness.

  • No evidence of distant metastasis.

Surgical Treatment

Surgical treatment was decided at the Tumor Board meeting.

  • Procedure: Robotic-assisted Ivor-Lewis esophagectomy with 2-field lymphadenectomy.

  • Postoperative Course: Uneventful post-operative period. Patient discharged in 8 days.

Final Pathology

  • Pathological Stage: ypT0, ypN0 (0/33), L0, V0, Pn0, R0.

  • Histopathological Response: Complete histopathological response.

Postoperative Follow-up

Clinical, radiologic and endoscopic follow-up with no evidence of recurrence or distant metastasis so far.

Presentation of the Case

Prof. Peter Grimminger (Mainz)

Discussion Points

  1. The role of totally robotic assisted surgery in the treatment of locally advanced tumors of distal esophagus

  2. Tailored treatment of advanced esophageal carcinoma

Panel of Experts for Discussion

Philip Chiu (Hong Kong) | Klaus Emmanuel (Salzburg) | Caterina Froiio (Milan) | Magnus Nilsson (Stockholm) | Richard Van Hillegersberg (Utrecht)