What is the treatment for gastroesophageal junction adenocarcinoma?
Treatment for gastroesophageal junction adenocarcinoma is dependent upon the tumor stage and can involve a combination of different methods.
Surgical removal (resection) of the tumor is indicated when possible. Stage I and II esophageal cancers are potentially removable, along with most stage III cancers, if they have not grown into important organs like the windpipe or aorta. Stage IV tumors have spread to distant sites in the body and are not able to be removed by surgery. Cancers of the gastroesophageal junction, when possible, are treated by surgically removing part of the stomach, the cancer, and a portion of the normal esophagus above the cancer. The stomach is then connected to the remaining part of the esophagus. Nearby lymph nodes are also removed to check for the presence of cancer cells.
Neoadjuvant therapy is treatment that is given before surgery to try to shrink the tumor to make the surgery easier. Neoadjuvant therapy may be given in the form of radiation or chemotherapy or a combination of the two.
Endoscopic mucosal resection (EMR) is a technique that removes sections of the lining of the esophagus, done through an endoscope as described above. This technique is only suitable for very small early stage cancers.
Photodynamic therapy (PDT) is also used to treat small cancers and precancerous changes. Porfimer sodium (Photofrin), a light-activating drug, is first injected into a vein. The drug collects in cancer cells over a time period of a few days. Using an endoscope, a laser light is then directed on the cancer. The drug reacts with the light and changes into a substance that destroys cancer cells, which are later removed with an endoscope. This can be used to remove small cancers or to reduce the size of large cancers to improve swallowing ability. It is limited in its ability to only destroy parts of the tumor that can be accessed by the laser light source, so deeper parts of the tumor cannot be treated.
Other treatments including electrocoagulation and laser ablation are sometimes carried out to keep the esophagus open and help the affected person swallow. These involve the localized destruction of cancer cells using laser or electric energy. Placement of a stent to keep the esophagus open is also sometimes performed via endoscopy.
Chemotherapy involves the administration of drugs into the body that kill rapidly dividing cancer cells. Chemotherapy may be given after surgery (in this case known as adjuvant therapy) or prior to surgery to shrink a tumor (neoadjuvant therapy). It is often given along with radiation therapy.
Different chemotherapy drugs have been used to treat gastroesophageal junction cancers. A regimen known as ECF, consisting of epirubicin (Ellence), cisplatin, and 5-fluoruracil (5-FU), is often given for gastroesophageal junction tumors. Other drugs that have been used include carboplatin, paclitaxel (Taxol), docetaxel (Taxotere), capecitabine (Xeloda), oxaliplatin, and irinotecan (Captosar).
Radiation therapy uses high-energy particles or rays to destroy cancer cells. It may be given along with chemotherapy (known as chemoradiation), either before or after surgery. It can also be used to relieve symptoms in the cases of advanced gastroesophageal junction cancer like pain, bleeding, and trouble swallowing. This type of treatment is referred to as palliative treatment or palliation.
Targeted therapy drugs are medicines that work against a particular molecular abnormality or "target" found on cancer cells. This is a newer type of treatment than chemotherapy.
Trastuzumab (Herceptin) and ramucirumab (Cyramza) are two targeted therapy drugs that have been used to treat advanced esophageal cancers. Trastuzumab is used to treat cancers that over express a protein known as HER-2 that drives cell growth. Ramucirumab targets a protein known as VEGF that directs cancers to make new blood vessels. Ramucirumab is used to treat advanced cancers of the gastroesophageal (GE) junction, typically when other drugs have stopped working.
A new type of cancer treatment involves the use of drugs that target so-called "checkpoints" of the immune system. The normal immune system has built-in checkpoints that protect the body from attacks by its own immune system. Pembrolizumab (Keytruda) is a drug that blocks a known immune system checkpoint.. It targets PD-1, a protein on immune system T cells that helps keep these cells from attacking normal cells in the body. By blocking PD-1, the drug stimulates the body to mount an immune response against cancer cells. This drug has been used in some people with advanced gastroesophageal junction adenocarcinomas who have had at least two previous treatments that have stopped working.