Palliative Multimodality-Therapy, Even With Abbreviated Immunotherapy Can Make Curative Surgery for Synchronous Lung and Esophageal Cancer Possible: A Case Report

Abstract Background Synchronous lung and esophageal carcinomas are problematic. When both cancers are locally advanced, combined surgical treatment is rarely possible because of high-risk or insufficient respiratory reserve. Palliative treatment including immunotherapy can sometimes offer significant tumor response and potentially prolong survival in patients with PDL-1 tumor expression. However the place of immunotherapy for potentially rendering inoperable patients operable is still unknown. Methods Case report: A 78-year-old male with smoking history was diagnosed with synchronous locally advanced adenocarcinoma of the Gastroesophageal Junction (GEJ) cT3cN1cM0 and bilateral lung adenocarcinomas stage 4a, cT2cN1cM1a (right lower lobe 43mm confirmed by CT-guided biopsy, left upper lobe 32mm and additional S6 left lower lobe nodule). The patient was considered incurable by MDT and palliative treatment was offered as both cancers had significant PDL-1 expression (GEJ: CPS score 1, Lung: PDL-1 expression 90%). Pembrolizumab immunotherapy was started but poorly tolerated (severe myositis) and stopped again after only 6 weeks. The left-sided lung cancer had by then already regressed and stereotactic irradiation (SBRT 5x12Gy) of the right-side lung cancer was administered resulting in further local tumor control (figure). Endoscopic tumor re-evalution showed a Siewert type 2 tumor (uT3N1) similar to the initial endoscopy 15 months before. Both side lung adenocarcinomas remained regressed and the left lower lobe nodule was unchanged (6mm). Mediastinal lymph node staging by EBUS was negative. Thirteen months after initial diagnosis, 4 cycles of neo-adjuvant chemotherapy (FLOT) were administered. Combined synchronous surgery was finally done 16 months after initial diagnosis. A minimally invasive combined resection included a laparoscopic & thoracoscopic Ivor-Lewis MIE, left thoracoscopic wedge of the lower lobe nodule and a right lower lobectomy with radical lymph node dissection. Post-operative course was smooth: Clavien-Dindo score 1, hospital stay 18 days. Final pathology Distal third adenocarcinoma (1.5x1.2cm above Z-line) with major partial response ypT2N0M0, R0, 0/43 lymph nodes (subcarinal signs of nodal response), right lower lobe tumor of 60x55mm with residual 1.2mm focus of residual viable adenocarcinoma (ypTisN0M0, R0) and left lower lobe hamartoma (6mm). Follow-up showed no recurrence 9 months after surgery (25 months from initial diagnosis). Conclusions: 1) Despite much abbreviated palliative immunotherapy (6 weeks), SBRT and FLOT our patient was down-staged within 16 months from an initially palliative situation to a potential cure with complete resection of all tumors. 2) Synchronous combined radical laparoscopic & thoracoscopic Ivor-Lewis esophagectomy with lung lobectomy can be feasible after immuno-, chemo- and radiotherapy even in elderly patients.