Follow Up and Surveillance of Esophageal Cancer Treated With Curative Intent

Follow Up and Surveillance of Esophageal Cancer Treated With Curative Intent

  • Authors: Anne-Sophie Laliberté, MD. FRCSC
  • Reviewers : Brian Johnston and Andrew Seely

Society recommendations

Based on society recommendations and expert consensus, there is no high level of evidence to guide in the development of algorithms.

The majority of recurrences (44%)1 occur in the first two years following cancer treatment, but some have been described up to more than 5 years after. (NCCN)

In case of squamous cell carcinoma, we need to consider the possibility of metachronous cancer.

Incidence of esophageal cancer in Canada:

In 2019, Canadian Cancer Society estimate:

  • 2,300 Canadians will receive a diagnosis of esophageal cancer
  • 2,200 Canadians will die of esophageal cancer

Society recommendations reviewed:

Canadian, American, and French guidelines and recommendations were reviewed.

  • National Comprehensive Cancer Network (2019)
  • Canadian Cancer Society (2019)
  • NICE guidelines (2018)
  • Cancer Care Ontario
  • Thesaurus recommendations (2016)
  • ESMO Clinical Practice Guidelines (2013)
  • French guidelines OncoLogik (2019)

Follow up and surveillance of surgical patient by stage and type of resection:

Clinical and Physical examination:

  • Clinical and physical examination is recommended for all stages, the frequency is variable between the different society recommendations.
  • Follow up at 3, 6, 12, 18, 24 months and then annually.
  • Smoking cessation is recommended
  • Unscheduled evaluation if patient become symptomatic

.

Early Stage – Stage I:

Abbreviations

  • EMR: Endoscopic mucosal resection
  • RFA: Radiofrequency ablation
  • ESD: Endoscopic submucosal resection

.

Advanced Stage – Stage II&III:

Recommendations:

Summary of recommendations for endoscopic and radiologic surveillance after esophageal cancer resection
Stage Endoscopic surveillance Radiologic surveillance
Stage I – Recommended for local resection only: every 3months for one year, then every 6 months for the second year and then annually

– Recommended if residual Barrett’s esophagus

– Treatment of persistent Barrett’s esophagus is recommended

– Radiologic surveillance isn’t recommended for Tis and T1a

– Annual CT-scan for 3 years is recommended for pT1b

Stage II & III – No evidence to recommend Endoscopic – CT-scan every 6 months for 2 years then annually

 

Summary of recommendations for endoscopic and radiologic surveillance after definitive chemoradiation for esophageal cancer
Stage Endoscopic surveillance Radiologic surveillance
Stage I – Endoscopic surveillance every 3-6 months for 2 years then annually – CT-scan every 6-9months if patient candidate for salvage esophagectomy
Stage II & III – Endoscopic surveillance every 3-6 months for 2 years, then every 6 months for the third year then clinically/ annually. – CT-scan every 6 months for the first 2 years if patient candidate for salvage esophagectomy, then clinically/annually.

Lifelong follow up is recommended.


Bibliograpy

Society

  • National Comprehensive Cancer Network (2019)
  • Canadian Cancer Society (2019)
  • Cancer Care Ontario
  • Thesaurus recommendations – Thésaurus National de Cancérologie Digestive (publish 23/09/2016)
  • French guidelines OncoLogik ( Esophageal adenocarcinoma :publish 14/05/2019 and Squamous cell carcinoma: publish 28/06/2018)

Articles

  1. Du Rieu M.C., Filleron T., Beluchon B. et al.Recurrence risk after Ivor Lewis oesophagectomy for cancer. Journal of Cardiothoracic Surgery 2013,8:213
  2. Mariam Naveed and Nisa Kubilium. Endoscopic Treatment of Early-Stage Esophageal Cancer. Curr Oncol Rep (2018) 20:71.
  3. Sharma, D. Katzka, N. Gupta et al. Quality Indicators for the Management of Barrett’sEsophagus, Dysplasia, and Esophageal Adenocarcinoma: Internation Consensus Recommendations from the American Gastroenterological Association Symposium. Gastroenterology. 2015;149(6):1599-1606.
  4. Stahk, C. Mariette, K. Haustermans et al. Oesophageal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow up. Ann Oncol 2016;27 (suppl.5):v50-57

Best Practice Recommendations on Enhanced Recovery after Thoracic Surgery (ERATS) for Esophagectomy

N Seyednejad, B. Johnson, G. Darling, A. Seely

Background

Enhanced Recovery After Surgery aims to approach the care of surgical patients in a multimodal, multidisciplinary manner to in order to improve surgical outcomes and quality of care. Enhanced Recovery After Surgery (ERAS) programs are becoming the standard of practice in many surgical specialties throughout the world. Data on implementation of ERAS pathways at many centres have demonstrated improvements in clinical outcomes, patient satisfaction, and results in significant cost savings to the health care system. While ERAS has been widely implemented across the country in various oncological specialties, its uptake for ERATS procedures have been slower and extensively documented. Here, we outline the recommendations for ERATS in patients undergoing an esophagectomy.

Recommendations

Preoperative
  1. Nutritional assessment and optimization:
    • Early involvement / consultation of dietician
    • Use of pharmaco-nutrition when necessary: e.g. Ensure, Boost, or Resource TID
  1. Pre-rehabilitation and exercise regimen:
    • Recommendations for daily exercise: i.e. 45 minute walk daily
  1. Complete smoking cessation:
    • Any duration of time prior to surgery; at least 4 weeks prior to surgery highly advised
    • Nicotine replacement as necessary
  1. Discharge planning:
    • Managing postoperative expectations
    • Patient education i.e. information booklets, outlining what patients should expect in the immediate post operative settings (i.e. drains/chest tubes, analgesic management) and upon discharge
    • Early involvement of allied team members i.e. social worker, nurse educator
  1. Timing of Surgery:
    • 3-6 weeks following completion of chemotherapy
    • 6-10 weeks following the completion of radiation after chemoradiation
  1. Bowel Preparation:
    • Routine use of bowel prep not currently recommended
Intraoperative
  1. Standardized best practice anesthesia:
    • Maintain euvolemia
    • Low tidal volumes / lung protective ventilation
  1. Minimally invasive techniques:
    • Laparoscopic abdominal approach preferred when possible; currently controversial, no conclusive evidence available
    • Thoracoscopic chest approach if possible
  1. Minimized use of chest tubes, drains:
    • Eg. 1 chest tube in right pleural cavity
  1. Use of enteric feeding tubes (i.e. nasoduodenal or jejunostomy) is generally recommended, especially if pre-operative malnutrition present:
    • Selective avoidance of feeding tubes reasonable (e.g. no pre-operative malnutrition, no anastomotic concerns)
  1. Optimal multimodal analgesia
    • Use of paravertebral analgesia over a thoracic epidural
    • Regular acetaminophen dosing
    • Limited opioid use
    • NSAID use controversial due to concern for increased risk for anastomotic leak (see references 4 & 6)
Postoperative
  1. Optimal Multimodal analgesia:
    • Early transition to oral/enteral analgesics
    • Minimal use of intravenous opioids
  1. Early oral nutrition:
    • Initiate early oral fluids (e.g. 2 days of sips of water, followed by 2 days of clear fluids, followed by 2 days of full fluids based on recent randomized controlled trial demonstrating no increased risk of adverse events) – see reference 1
    • Patients to stay on full fluids on discharge, until POD7, then transition to post esophagectomy diet
  1. Early Mobilization:
    1. Assisted mobilization (i.e. first steps) POD0
    2. Independent mobilization POD1
  1. Early removal of tubes and drains if no clinical contraindications:
    1. Eg. Removal of Foley catheter POD1 if no epidural (D/C foley on day of epidural discontinuation otherwise)
    2. Eg. Chest tube removal POD3 if no evidence of air leak, chyle leak
    3. Eg. JP Drain removal POD6
    4. Eg. Remove NG POD3 ager clamping evening of POD2 and if no evidence of gastric conduit distention
  2. Optimized glycemic control to normalized levels to promote healing (goal <10mmol/L):
  3. Target timeline to discharge (without any):
    • POD6

 

References

  1. Berkelmans GH, Fransen LF, Dolmans-Zwartjes AC, Kouwenhoven EA, van Det MJ, Nilsson M, Nieuwenhuijzen GA, Luyer MD. Direct oral feeding following minimally invasive esophagectomy. Annals of Surgery
  2. Chao L, Ferri L, Mulder S, Ncuti A, Neville A, Lee L, Kaneva P, Watson D, Vassiliou M, Carli F, Feldman L. An enhanced recovery pathways decreases duration of stay after esophagectomy. Surgery 2012: 606-616.
  3. Findlay J, Gillies R, Millo J, Sgromo B, Marshall R, Maynard N. Enhanced recovery for esophagectomy: A systematic review and evidence based guidelines. Ann of Surgery 2014; 259:413-431.
  4. Fjederholt KT,Okholm C,  Svendsen LB, Achiam MP, Kirkegård J, Mortensen FV. Ketorolac and Other NSAIDs Increase the Risk of Anastomotic Leakage After Surgery for GEJ Cancers: a Cohort Study of 557 Patients. J Gastrointestinal Surg 2018: 587-594.
  5. Giménez-Milà M, Klein AA, Martinez G. Design and implementation of an enhanced recovery program in thoracic surgery. Journal of thoracic disease 2016 Feb;8(Suppl 1):S37.
  6. Hakkarainen TW, Steele SR, Bastaworous A, Dellinger EP, Farrokhi E, Farjah F, Florence M, Helton S, Horton M,, Pietro M, Varghese TK, Flum DR. Nonsteroidal anti-inflammatory drugs and the risk for anastomotic failure: a report from Washington State’s Surgical Care and Outcomes Assessment Program (SCOAP). JAMA Surg 2018; 223-228.
  7. Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A review. JAMA Surg 2017; 152:292-298.
  8. Low DE, Allum W, De Mazoni G, Ferri L, Immanuel A, Kuppusamy M, Law S, Lindblad M, Maynard N, Neal J, Pramesh C, Scott M, Smithers B, Addor V, Ljungqvist O. Guidelines for perioparative care in esophagectomy : enhanced recovery after surgery (ERAS) society recommendations. World J of Surgery 2018; 43:299-330.
  9. Markar S, Karthikesaligam A, Low D. Enhanced recovery pathways lead to an improvement in postoperative outcomes following esophagectomy: systematic review and pooled analysis. Disease of the esophagus 2015; 28: 468-475.
  10. Martin LW, Sarosiek BM, Harrison MA, Hedrick T, Isbell JM, Krupnick AS, Lau CL, Mehaffey JH, Thiele RH, Walters DM, Blank RS. Implementing a thoracic enhanced recovery program: lessons learned in the first year. The Annals of thoracic surgery 2018; 105(6):1597-604.
  11. Thiele RH, Rea KM, Turrentine FE, Friel CM, Hassinger TE, Goudreau BJ, et al. Standardization of Care: Impact of an Enhanced Recovery Protocol on Length of Stay, Complications, and Direct Costs after Colorectal Surgery. Journal of the American College of Surgeons 2015; 220:430–43.


Recommendation for Thoracic Surgery Perioperative VTE Prophylaxis.


Background:

It is now widely accepted that the true incidence of post-op VTE following lung and esophageal resection is largely under-reported. A large range of incidence has been reported, with variations mainly related to different detection methods, type and duration of prophylaxis, and the subclinical nature of a significant proportion of VTE occurrence. Thoracic surgery poses an increased risk of postop VTE given the high prevalence of oncologic surgery, the protracted post-operative recovery, and the direct manipulation of the lung and pulmonary vascular anatomy.

CATS Recommendations

CATS members continue to be involved in research evaluating the optimal method and duration for post-thoracic surgery VTE prophylaxis. The committee recognizes however the paucity of high-level evidence in this field. As higher level evidence emerges, CATS hopes that a unified approach to postop VTE prophylaxis can serve as a starting point to adopt new guidelines for in-hospital and post discharge care.

  1. Post Thoracic surgery in-hospital prophylaxis = LMWH or LDUH +/- mechanical compression
  2. No recommendation for extended prophylaxis = use at surgeon’s discretion
  3. Symptomatic postop VTE = Thrombosis referral + therapeutic anticoagulation

Summary of the Evidence

  • Most data is based on retrospective single-institution cohort studies.
    • Results are challenged by the retrospective nature of the studies, dependence on symptomatic diagnosis and not asymptomatic screening, and lack of recognition of de novo PE without DVT
    • Estimates of postop incidence: 5-15.2%
  • More recent research has evaluated prevalence of post-lung resection VTE using screening strategies in a prospective fashion
    • Prospective screening studies
      • CTPA 7-15 days postop = prevalence of 14%
      • B/L Doppler U/S + CTPA @ 30-days postop = prevalence 12.1%
    • 23% of VTE occur post-discharge & Post-pneumonectomy peak incidence à >7 days postop
    • Cohort of 2,373 cancer patients identified that 40% of VTE occurred >21 days post discharge
  • Canadian Delphi Survey including CATS members (Journal Thorac Dis. 2017 Jan; 9(1)80-87)
    • Strong agreement in identifying risk factors for VTE, and which of those factors may potentially influence the decision for extended post-hospital discharge prophylaxis.
    • Limited agreement on the type of prophylaxis (pharmacological, mechanical and/or both), as well as the initiation and duration of thromboprophylaxis—indicating high degree of variability
    • The only reliable factor of agreement was the use of LMWH in hospital

ACCP 9th Edition Guidelines for Thoracic Surgery

  • Moderate risk for VTE + not high bleeding risk à LDUH or LMWH (Grade 2B), or MCS (Grade 2c)
  • High risk for VTE + not high bleeding risk à LDUH or LMWH (Grade 1B) + MCS (Grade 2C)
  • High risk for Major bleeding à MCS with optimally applied IPC (Grade 2C)
  • No recommendation for extended post-discharge prophylaxis.