Life After Treatment: Surveillance for Esophageal Cancer and Managing Recurrence

Most of these patients go on to develop stricturous disease, leading to significant dysphagia and a chronic inability to take oral nutrition. In such patients, an esophagectomy with a neo-esophagus is offered. In patients who do not develop stricturous disease, six-monthly endoscopic evaluation with biopsy of any suspicious area is done instead, and further imaging is not required unless a biopsy proves malignancy.

The protocol is endoscopic mapping. The endoscopist localises exactly where the tumour sits relative to the GE junction, using a standard landmark of around 40 cm from the incisors, which varies slightly with the patient's own oesophageal length. Once that is determined, the malignancy is mapped against the gastroesophageal junction, and this is cross-checked against the axial imaging. If there is any disagreement between the endoscopic and imaging findings, the axial imaging representation is preferred to finalise the diagnosis.

Immunotherapy's role is currently established in the adjuvant setting, more so for esophageal squamous cell carcinoma. A patient who completes neoadjuvant therapy, undergoes surgery, and is found to have residual disease is followed with adjuvant nivolumab. If there is no residual disease, adjuvant nivolumab is not advocated. In the neoadjuvant setting, the role of immunotherapy is still experimental and yet to be answered.

Cryotherapy, along with other ablative therapies, is applicable only in very early and especially screen-detected cases of esophageal malignancy. Staging accuracy is critical here: if endoscopy and endoscopic ultrasound confirm a flat, high-grade dysplastic lesion or an early intramucosal carcinoma, ablation can be applied, though it does leave structural changes at the site that make future surveillance harder. If there is any suspicion of nodular disease, or of invasion into the submucosa or muscularis propria, endoscopic resection is recommended over an ablative procedure like cryotherapy alone.

This is a question on my mind as well. There is no established genetic risk factor explaining why esophageal cancer is more common in men than women. A lot of it is attributed to other risk factors instead, like smoking habits and diet habits, but on the genetic side there really isn't an answer yet.

Endoscopic surveillance every three months in year one, every six months in year two, and annually thereafter.

Contrast-enhanced CT or PET imaging every six months for the first two years, then annually through the first five years, alongside continued endoscopic surveillance for patients treated with definitive chemoradiation.

Salvage surgery is offered to patients fit enough to tolerate it.

Not reliably yet. There is currently no way to confirm a true pathological complete response with PET and endoscopy alone, which is what would be needed before esophagectomy could be safely avoided in more patients.