A 62-year-old man with a 40-year history of smoking presents with progressive dysphagia to solids for 3 months and unintentional weight loss of 8 kg. Endoscopy reveals a 5 cm ulcerated lesion in the mid-esophagus. Biopsy confirms squamous cell carcinoma. CT chest/abdomen shows no distant metastases, but there is invasion into the adjacent aorta. Which of the following is the most appropriate treatment strategy?

Explanation

## Locally Advanced Esophageal Cancer with Aortic Invasion **Key Point:** Aortic invasion is considered locally advanced disease (T4b) but NOT an absolute contraindication to curative intent therapy if there is no distant metastasis and the patient has adequate performance status. **Correct Answer: Definitive Concurrent Chemoradiation Therapy Alone** ### Rationale: - **Aortic invasion (T4b):** Makes the tumor unresectable by standard esophagectomy, as en bloc resection of the aorta carries prohibitive morbidity/mortality - **Current evidence (CROSS, RTOG 8501, NCCN guidelines):** Concurrent chemoradiation (CCR) is the standard of care for unresectable locally advanced esophageal cancer - **Survival outcomes:** CCR achieves 5-year survival of 20–30% in locally advanced disease, with acceptable toxicity - **Why not surgery:** Aortic invasion makes R0 resection impossible without major vascular reconstruction, which is not standard in esophageal cancer - **Performance status:** Patient is suitable for CCR (no mention of poor PS) ### High-Yield: T4b (aortic invasion) → CCR is curative intent. Neoadjuvant chemo + surgery is for resectable T4a (pleura/pericardium). ### Clinical Pearl: If patient had T4a (pleura/pericardium invasion) without aortic involvement, neoadjuvant chemotherapy + esophagectomy would be appropriate.