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Gastroesophageal Cancer: Diagnostic Workup

Panelists: Johanna C. Bendell, MD, Sarah Cannon Research Institute; Ian Chau, MD, Royal Marsden Hospital; Yelena Y. Janjigian, MD, Memorial Sloan Kettering Cancer Center; Manish A. Shah, MD, Weill Cornell Medicine, New York-Presbyterian Hospital; Kohei Shitara, MD, National Cancer Center Hospital East, Japan
Published: Wednesday, Jun 28, 2017



Transcript:

Johanna C. Bendell, MD:
Manish, when you go to your hospital and you have a new patient with locally advanced disease, who helps you and who works together as a team to treat these patients and form a plan?

Manish A. Shah, MD: Right. So, that’s a great point. I think that it does take a team approach. We need the surgeon, the radiation oncologist, the pathologist, and the radiologist to help us with understanding the stage of the tumor, the other intricacies of where it is, and what type of cancer it is. And for patients with metastatic disease, you could argue that perhaps it’s not so important, but I think actually it is. Because, to Ian’s point, even with a patient who has an endoscopy and the tumor is in the proximal area, if there’s a risk of obstruction or whether a stent is an important aspect or not, these are things that can be done that require a team approach. And I think if we’re able to really work together, we’ll be able to give our patients the best outcomes.

Johanna C. Bendell, MD: Absolutely. And in Japan, is that the same as well, that you have a multidisciplinary team?

Kohei Shitara, MD: Yes, we also take a team approach. It’s usually 2 teams, the esophageal cancer team and the gastric cancer team, because the location of the tumor is very important. If it’s esophageal invasion or esophageal cancer, these patients are treated by the thoracic surgeon in contrast to our usual type of gastric cancer where patients are treated by our gastric surgeon. So, we have our 2 different teams. And, very importantly, at this time, adenocarcinoma in the esophagus is not so common in Japan; more common is the squamous type. And also, we do not currently use radiotherapy for adenocarcinoma in the stomach or esophagus. So, in this team, the radiologist usually belongs to the esophageal team, but not the gastric cancer team. But, anyway, a multidisciplinary approach is very important.

Johanna C. Bendell, MD: Yes. What you’re hearing here is these are very complicated GI cancers. This isn’t something like a laparoscopic colon resection. This is really a team approach, and not only with radiation oncologists, with medical oncologists, and surgeons, but even nutritionists, social workers, and exercise physiologists because these patients are also very sick. We make them very sick with treatment, too, before they get better and such. So, it’s important. And, with staging, how do you stage in Japan?

Kohei Shitara, MD: Usually patients with gastric cancer are detected by endoscopy and we do our biopsy, as mentioned by Ian. It is very important to evaluate the histology. At the same time, we do a CT scan to evaluate their deep mass of the primary tumor as well as their lymph node metastases. We do not commonly use a PET scan. We only use it for patients who we suspect have distant metastases, but it is not definitive. And at the same time, we also do a laparoscopy for peritoneal metastases, but it is also not for all patients. We only do it for a patient with a large primary tumor as well as a patient with suspicious peritoneal metastases, such as a skin rash-type gastric cancer.

Johanna C. Bendell, MD: Yes, but that’s a very good point for the more aggressive ones to check before you do the surgery. Manish, we’re in America. You’re in New York, which is money central. We like spending in our healthcare profession. What do you think about PET scans, endoscopic ultrasounds?

Manish A. Shah, MD: I would like to make a contrast with regard to the Japanese patients. In the West, most patients actually present with locally advanced disease, and I think that’s where we really do think of laparoscopy for staging for tumors, where a CT scan doesn’t show metastatic disease, is important, and that’s one key issue. The endoscopic ultrasound is important if we’re making a treatment decision based on that. We do think that based on part of Ian’s work from the MRC, perioperative therapy with chemotherapy is important for locally advanced disease. And sometimes you can’t tell on a CT scan if it is locally advanced, so an endoscopic ultrasound is useful for that. With regard to PET scans, it does identify occult disease in about 10% of patients, and those data are consistent with other malignancies as well. It is, of course, important for esophageal cancer to do PET scanning for occult metastatic disease. And in gastric cancer, it is done. But I agree with you; it’s not done routinely.

Ian Chau, MD: Certainly, we do PET scans as well as a routine, although the reason is more that we think that a PET scan is actually a cost-saving measure compared to a radical operation or unsuccessful open-and-close operation. So, actually, our surgeon view is that if you’ve got a PET scan and it actually ends up showing a metastasis, then you actually save the patient, most importantly, from an operation. We also routinely will do laparoscopy before we start any neoadjuvant therapy. I don’t know whether the Japanese send cytology or lavage and cytology in laparoscopy and what do they do with the results. Because our surgeons certainly have a very mixed view about it, and some said they would, but others argue that if you can’t see any microscopic peritoneal disease, what is the information that is given by the cytology?

Kohei Shitara, MD: It is a very complicated, or controversial, issue even in Japan. We also have a policy for peritoneal metastases. Treatment for these patients is very controversial. If a patient had some symptoms, specifically from a primary tumor, usually chemotherapy is a choice for treatment. But recently, activity of chemotherapy would implore this. So, more and more treatment is shifting for a neoadjuvant treatment strategy, dual chemotherapy, second laparoscopic examination, and then proceed with a radical surgery.

Johanna C. Bendell, MD: It seems like what we’re hearing in this conversation is the importance of making sure, especially when patients are locally advanced—they’re not metastatic—there is the multidisciplinary team approach, but also the potential for referral to a specialized center that can help make some of these decisions, work on some of the staging, and try to put a good treatment plan together for these patients. And especially with the surgeons, to make sure that even when you have ones that depend on how high or where it’s located within the gastroesophageal milieu, you might have a different surgeon who’s doing the operation or sometimes a combination of the 2.

Transcript Edited for Clarity

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Transcript:

Johanna C. Bendell, MD:
Manish, when you go to your hospital and you have a new patient with locally advanced disease, who helps you and who works together as a team to treat these patients and form a plan?

Manish A. Shah, MD: Right. So, that’s a great point. I think that it does take a team approach. We need the surgeon, the radiation oncologist, the pathologist, and the radiologist to help us with understanding the stage of the tumor, the other intricacies of where it is, and what type of cancer it is. And for patients with metastatic disease, you could argue that perhaps it’s not so important, but I think actually it is. Because, to Ian’s point, even with a patient who has an endoscopy and the tumor is in the proximal area, if there’s a risk of obstruction or whether a stent is an important aspect or not, these are things that can be done that require a team approach. And I think if we’re able to really work together, we’ll be able to give our patients the best outcomes.

Johanna C. Bendell, MD: Absolutely. And in Japan, is that the same as well, that you have a multidisciplinary team?

Kohei Shitara, MD: Yes, we also take a team approach. It’s usually 2 teams, the esophageal cancer team and the gastric cancer team, because the location of the tumor is very important. If it’s esophageal invasion or esophageal cancer, these patients are treated by the thoracic surgeon in contrast to our usual type of gastric cancer where patients are treated by our gastric surgeon. So, we have our 2 different teams. And, very importantly, at this time, adenocarcinoma in the esophagus is not so common in Japan; more common is the squamous type. And also, we do not currently use radiotherapy for adenocarcinoma in the stomach or esophagus. So, in this team, the radiologist usually belongs to the esophageal team, but not the gastric cancer team. But, anyway, a multidisciplinary approach is very important.

Johanna C. Bendell, MD: Yes. What you’re hearing here is these are very complicated GI cancers. This isn’t something like a laparoscopic colon resection. This is really a team approach, and not only with radiation oncologists, with medical oncologists, and surgeons, but even nutritionists, social workers, and exercise physiologists because these patients are also very sick. We make them very sick with treatment, too, before they get better and such. So, it’s important. And, with staging, how do you stage in Japan?

Kohei Shitara, MD: Usually patients with gastric cancer are detected by endoscopy and we do our biopsy, as mentioned by Ian. It is very important to evaluate the histology. At the same time, we do a CT scan to evaluate their deep mass of the primary tumor as well as their lymph node metastases. We do not commonly use a PET scan. We only use it for patients who we suspect have distant metastases, but it is not definitive. And at the same time, we also do a laparoscopy for peritoneal metastases, but it is also not for all patients. We only do it for a patient with a large primary tumor as well as a patient with suspicious peritoneal metastases, such as a skin rash-type gastric cancer.

Johanna C. Bendell, MD: Yes, but that’s a very good point for the more aggressive ones to check before you do the surgery. Manish, we’re in America. You’re in New York, which is money central. We like spending in our healthcare profession. What do you think about PET scans, endoscopic ultrasounds?

Manish A. Shah, MD: I would like to make a contrast with regard to the Japanese patients. In the West, most patients actually present with locally advanced disease, and I think that’s where we really do think of laparoscopy for staging for tumors, where a CT scan doesn’t show metastatic disease, is important, and that’s one key issue. The endoscopic ultrasound is important if we’re making a treatment decision based on that. We do think that based on part of Ian’s work from the MRC, perioperative therapy with chemotherapy is important for locally advanced disease. And sometimes you can’t tell on a CT scan if it is locally advanced, so an endoscopic ultrasound is useful for that. With regard to PET scans, it does identify occult disease in about 10% of patients, and those data are consistent with other malignancies as well. It is, of course, important for esophageal cancer to do PET scanning for occult metastatic disease. And in gastric cancer, it is done. But I agree with you; it’s not done routinely.

Ian Chau, MD: Certainly, we do PET scans as well as a routine, although the reason is more that we think that a PET scan is actually a cost-saving measure compared to a radical operation or unsuccessful open-and-close operation. So, actually, our surgeon view is that if you’ve got a PET scan and it actually ends up showing a metastasis, then you actually save the patient, most importantly, from an operation. We also routinely will do laparoscopy before we start any neoadjuvant therapy. I don’t know whether the Japanese send cytology or lavage and cytology in laparoscopy and what do they do with the results. Because our surgeons certainly have a very mixed view about it, and some said they would, but others argue that if you can’t see any microscopic peritoneal disease, what is the information that is given by the cytology?

Kohei Shitara, MD: It is a very complicated, or controversial, issue even in Japan. We also have a policy for peritoneal metastases. Treatment for these patients is very controversial. If a patient had some symptoms, specifically from a primary tumor, usually chemotherapy is a choice for treatment. But recently, activity of chemotherapy would implore this. So, more and more treatment is shifting for a neoadjuvant treatment strategy, dual chemotherapy, second laparoscopic examination, and then proceed with a radical surgery.

Johanna C. Bendell, MD: It seems like what we’re hearing in this conversation is the importance of making sure, especially when patients are locally advanced—they’re not metastatic—there is the multidisciplinary team approach, but also the potential for referral to a specialized center that can help make some of these decisions, work on some of the staging, and try to put a good treatment plan together for these patients. And especially with the surgeons, to make sure that even when you have ones that depend on how high or where it’s located within the gastroesophageal milieu, you might have a different surgeon who’s doing the operation or sometimes a combination of the 2.

Transcript Edited for Clarity
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