Esophageal stent

Neoadjuvant long-term radiochemotherapy for both rectal and esophageal tumors. 

Simultaneous: Ivor-Lewis esophagectomy (two-field lymphadenectomy) and low anterior resection with TME. If the esofagectomy lasts to many hours - Hartman's resection.

If the patient is to frail and a two-staged procedure would be better, I think that the esophagus should be resected first, taking into account rectal tumor response to preoperative CxRT. 

thanks Dr Negoi

i suppose the simultaneous surgery for patient at this age is risky and if a complication happens ,it is too difficult to manage the patient.

i myself prefer to perform in two stage after neoadjuvant chemoradiation. but i don't know it is feasible  in point of view of radiotherapist.

This might be a random phenomenon unless there were biomarkers indictinga biologic overlap.

PET scan clear? Staging lap for the eaophageal tumour? I don't think you can decide on a surgical plan just yet; it will depend on the response of each (if non-related tumours) to neoadj Rx 

Dear Dr Kamal

Thanks for your replay, I agree with PET scan but there is not indication for laparoscopic staging for esophagus cancer according NCCN guideline.

we ordered for PET scan ,when the result is ready i will inform you.

Guidelines are guidance; these vary in diff countries. I'm not too sure there are detailed, evidence-based, mandatory guidelines for atypical cases. In this case, I would use all means of ensuring there are no tiny intraperitoneal nodules; you loose nothing. Plus, if the dysphasia is severe and not stentable you could insert a feeding jejunostomy at the same time

Thanks again dr kamal ,nice comment 

Some may consider surve as part of treatment for te rectal cancer. hr

hello

pet scan showed no metastasis.

M0 is no ontradiction for surgery

In my opinion there was no indication for PET-CT. However, if it was performed may be useful for evaluating esophageal and rectal tumor response to neoadjuvant CxRT (decrease in 18F-FDG SUV).

Did the patient received an esophageal stent and did you start neoadjuvant chemoradiation for both tumors ? 

In the UK PET and laparoscopy would be standard. Presuming the lap normal, both are operable but there is higher mortality from the oesophagus and a high chance of local recurrence from the rectum. Thus, I would use long course radio for the rectum with full dose chemo for the oesophagus. Following this, I would restage completely, aiming to operate on the oesophagus first, if there was no progress after chemo. Delaying rectal surgery after radio might actually be of benefit and getting over the oesophagectomy is usually more difficult for the patient. Of course, neo-adjuvant treatment could result in 6 combinations of results, so pending restaging a management plan remains hypothetical. The patient's nutrition and tolerance of treatment would be my primary concern, thus I would be directed by the patient. Best of luck. Do report back in 12 weeks!

Thanks Dr Ionut

Thanks Dr Kamal

According NCCN guideline pet scan is indicated for non metastatic oesophageal cancer

and laparoscopy staging is recommend only for T3 N1 or higher stage (cat 2a)

it is a very difficult case and patient has no dysphagia and as dr kamal told the survival is based to esophagus ca. so the treatment of esophagus is urgent but the standard of care for esophagus for my patient is chemoradiation and time consumption for neoadjuvant of esophagus and the recovery after surgery is so long that may be very dangerous for rectal cancer and the threat for distant mets or upgrade stage of it.

In fact, the point I was making is that for the oesophagus you don't have a time window; with the rectal you do. Hence, give neoadj,; operate on the oesophagus first. If the rectal shows distant mets on re-staging, they were already there. You do have more time and more options with the rectal....

There is not contraindication for removal of both tumors surgically, preferably by laparoscopic approach and if possible in the same intervention depending of its general health state and presence or not of other associated diseases

Dear Dr Luis

thanks for your following 

i suppose patient even with good performance can not tolerate two heavy surgeries.

and both surgery have dangerous complication.

Dear Dr Kamal

I am agree with you that survival of patient depend to esophagus cancer.

Excellent discussion and a very atypical case,so for in my long career Idid not come across one.He is 61yrs,no comorbities,Pet is negative.My preference is Lap trans hiatal esophagectomy same time deal with rectal Ca/Lap AR or APR.Then plan for adjuvant Therapy.Agree it takes about 4 to 5 hours and the morbidity but still it is worth considering.Nicely put it Guidelines are for guidance.Agree with Dr Luis,

To remove in first place the esophageal tumor has the added advantage to improve his nutrition before abrading the rectal tumor

agree

He needs some neo adjuvant treatment , at least chemotherapy . Provided all staging is supportive after chemotherapy then a dual resection is possible if the patient is very fit but I would be very tempted to exteriorise the colon (Hartmann‘S) or at the very least defunctioning ileostomy.

61yr man with no comorbidities,he is not obstructed,pet scan was done -therapy and the report was mentioned above,I am not clear about Neo adjuvant therapy and colostomy/ileostomy in a very uncommon case like this ! All you need is a experienced Laparoscopic surgeon,available in most of the centres across the Globe.once again it is a wonderful discussion.

You can afford both tumors simultaneously. Surgical excision of the esophageal tumor and pre-operative radiotherapy of the rectal tumor

Yes but if he leaks from either operation the mortality is extremely high.

Node positive Oesophageal cancer needs neo adjuvant chemotherapy / CRT as all the evidence suggests a survival benefit. To not give this treatment because of the synchronous tumours risks inadequately treating both. The chemo can be planned to cover both tumours. If the patient is fit for synchronous resection then fine, but you need to acknowledge the increased risk of a combined procedure and try to mitigate the effects of a complication. Even in the best series of results in the world the leak rate from oesophagectomy is still 12%. Assuming similar for rectum that’s a 1 in 4 chance of a life threatening leak in a patient who has had a massive operation. Laparoscopic surgery does not prevent these complications from happening so whilst I agree with the lap approach, i would still play safe

Agreed but leaks in the neck following esophagectomy can be managed with out any mortality,so as a protective ileostomy for LAR for rectal cancer.