OpenOnco · Treatment Plan

Treatment plan — Esophageal carcinoma

PLAN-ESOPH-CROSS-CM577-001-V1 · v1 · 2026-08-17

Patient

ESOPH-CROSS-CM577-001 · Algorithm: ALGO-ESOPH-RESECTABLE-1L

DiagnosisEsophageal carcinoma

MOH / ICD-10C15

ICD-O-38070/3; C15

StagecT3N1M0

Histologyadenocarcinoma

Clinical significance of mutations (ESCAT)

Tumor-board context — the engine does not use these tiers to rank tracks

✅ Covered biomarkers (matched in KB)

Biomarker	Variant	ESCAT	Evidence	Clinical significance	Drugs	Sources
ESCAT: clinical review pendingBIO-PDL1-CPS	(gene-level)	IA	SRC-NCCN-ESOPHAGEAL-2025 SRC-ESMO-ESOPHAGEAL-2024 Evidence cited from clinical guidelines; per-source evidence levels not yet structured. See Phase-2-of-CIViC-pivot for re-cite roadmap.	PD-L1 CPS used as eligibility threshold for ICI in metastatic esophageal cancer. Esophageal SCC: CPS ≥10 — pembrolizumab + cisplatin + fluoropyrimidine 1L (KEYNOTE-590), and pembrolizumab monotherapy 2L (KEYNOTE-181 CPS≥10 subgroup). Esophageal adeno and GEJ: same CPS criteria as gastric adeno (NCCN 2025 treats GEJ adeno with gastric algorithm). Testing by IHC 22C3 pharmDx mandatory. Threshold-gated indication selection is performed by the algorithm layer (IND-ESOPH-METASTATIC-2L-PEMBRO-CPS10); this BMA entry surfaces ESCAT tier context only.	pembrolizumab + cisplatin + fluoropyrimidine (CPS≥10 SCC 1L per SRC-NCCN-ESOPHAGEAL-2025) pembrolizumab monotherapy (CPS≥10 SCC/adeno 2L per SRC-NCCN-ESOPHAGEAL-2025)	SRC-NCCN-ESOPHAGEAL-2025 SRC-ESMO-ESOPHAGEAL-2024

⚠️ Not included in plan

Biomarker	Status
BIO-HER2-SOLID	Excluded (negative)
BIO-MSI-STATUS	BIO definition in KB; no ESCAT BMA entry — verify with clinician

Primary current-line option

Aggressive plan

★ DEFAULT

Indication

IND-ESOPH-ADJUVANT-NIVOLUMAB-POST-CROSS

Regimen

Nivolumab adjuvant — post-CROSS without pCR (CheckMate-577)

Drugs + NSZU

Nivolumab (DRUG-NIVOLUMAB) 240 mg IV q2w (cycles 1-16) then 480 mg IV q4w (until 1 year) · IV per protocol — total ~1 year of treatment · IV ⚠ NSZU — not for this indication

Hard contraindications

CI-PEMBROLIZUMAB-AUTOIMMUNE

Reason

Primary current-line option selected by ALGO-ESOPH-RESECTABLE-1L at step 0; branch-driving red flag: RF-ESOPHAGEAL-POST-CROSS-NON-PCR.

Other current-line alternatives (1 tracks)

Same treatment line; review when biomarker, access, contraindication, or patient-context assumptions change.

Standard plan

Indication

IND-ESOPH-RESECTABLE-CROSS-NEOADJUVANT

Regimen

Weekly carboplatin + paclitaxel (CROSS-style chemo backbone)

Drugs + NSZU

Carboplatin (DRUG-CARBOPLATIN) AUC 2 · IV weekly × 5 · IV ⚠ NSZU — not for this indication
Paclitaxel (DRUG-PACLITAXEL) 50 mg/m² · IV weekly × 5 · IV ✓ NSZU covered

Reason

Current-line alternative presented for HCP consideration

Why this branch was chosen

Triggers from the patient profile that fired and drove the chosen branch.

Step 0 → branch IND-ESOPH-ADJUVANT-NIVOLUMAB-POST-CROSS

RF-ESOPHAGEAL-POST-CROSS-NON-PCR ★ winner: Post-CROSS-CRT-then-esophagectomy with residual disease — pathology shows ypT+ and/or ypN+ (no pCR). ~70% of CROSS patients fall into this category. Treatment-defining: shifts the patient out of the resectable-1L (CROSS neoadjuvant) pathway into adjuvant nivolumab × 1 year per CheckMate-577 (DFS 22 vs 11 mo placebo, HR 0.69). Eligibility window: initiate within 4-16 weeks post-surgery. Applies to both adenocarcinoma and squamous-cell histology. SRC-NCCN-ESOPHAGEAL-2025SRC-ESMO-ESOPHAGEAL-2024

Pre-treatment investigations

Investigations before treatment start · critical / standard / desired · merged across tracks

ID	Name	Priority	Category	Where to order	Needed for
TEST-CT-CHEST-ABDOMEN-PELVIS	CT chest + abdomen + pelvis with IV contrast	Critical	imaging	—	standard
TEST-EGD-VARICES-SCREENING	Esophagogastroduodenoscopy with varices assessment	Critical	imaging	—	standard
TEST-CT-PET	PET-CT with FDG	Desired	imaging	—	standard

Red flags — PRO / CONTRA aggressive

PRO-AGGRESSIVE

Triggers that push toward the aggressive track

Severe dysphagia with weight loss / aspiration risk in esophageal cancer: inability to swallow saliva, recurrent aspiration pneumonia, >10% weight loss in 3 months, OR malignant tracheoesophageal fistula. Mandates urgent palliative intervention (stenting OR dilation OR diversion) BEFORE any definitive systemic / RT therapy.
Self-expandable esophageal stent OR endoscopic dilation OR PEG/J-tube for nutritional support. Tracheoesophageal fistula precludes RT (worsens fistula) — covered stent + chemo only. Severe weight loss pre-CROSS predicts poor tolerance —…
RF-ESOPH-SEVERE-DYSPHAGIA-ASPIRATIONSRC-NCCN-ESOPHAGEAL-2025SRC-ESMO-ESOPHAGEAL-2024
Post-CROSS-CRT-then-esophagectomy with residual disease — pathology shows ypT+ and/or ypN+ (no pCR). ~70% of CROSS patients fall into this category. Treatment-defining: shifts the patient out of the resectable-1L (CROSS neoadjuvant) pathway into adjuvant nivolumab × 1 year per CheckMate-577 (DFS 22 vs 11 mo placebo, HR 0.69). Eligibility window: initiate within 4-16 weeks post-surgery. Applies to both adenocarcinoma and squamous-cell histology.
Engine wiring: when post-CROSS non-pCR biology is detected on a patient profile that lacks `disease_state` (so the resectable-1L algorithm is the only line=1 esophageal algorithm reached by load-order fallback), this RedFlag fires inside…
RF-ESOPHAGEAL-POST-CROSS-NON-PCRSRC-NCCN-ESOPHAGEAL-2025SRC-ESMO-ESOPHAGEAL-2024

CONTRA-AGGRESSIVE

Hard contraindications to escalation

Pembrolizumab (and other PD-1/PD-L1 inhibitors) augment T-cell responses; in patients with active autoimmunity or post-transplant immunosuppression, this can precipitate severe organ-specific flares (colitis, hepatitis, pneumonitis, transplant rejection) that may be fatal or require transplant loss. CI-PEMBROLIZUMAB-AUTOIMMUNE

What NOT to do

Explicit prohibitive rules, each grounded in a regimen / supportive care / contraindication entity

Aggressive plan (IND-ESOPH-ADJUVANT-NIVOLUMAB-POST-CROSS)

Do NOT start in patients with pCR — no benefit shown (CheckMate-577 excluded)
Do NOT continue through Grade 3+ irAE without permanent discontinuation consideration
Do NOT delay start beyond 16 weeks post-surgery (protocol upper limit)

Standard plan (IND-ESOPH-RESECTABLE-CROSS-NEOADJUVANT)

Do NOT proceed to surgery without restaging post-CRT (occult progression detection)
Do NOT initiate RT without addressing severe dysphagia / aspiration risk first
Do NOT skip CheckMate-577 nivolumab adjuvant for residual ypT+ or ypN+ post-CROSS

Timeline

Treatment timeline — derived from regimen + monitoring schedule

Aggressive plan

Induction · Nivolumab adjuvant — post-CROSS without pCR (CheckMate-577)

14-day cycles × Up to 1 year per CheckMate-577 protocol (16 q2w + 7 q4w cycles approx)

Standard plan

Induction · Weekly carboplatin + paclitaxel (CROSS-style chemo backbone)

7-day cycles × 5 weekly cycles concurrent with RT 41.4 Gy in 23 fractions (CROSS protocol)

MDT brief

Discussion questions (1, 0 blocking)

OQ-LDH-CURRENT
What is the current LDH? Marker of tumor burden and transformation.
LDH is part of the prognostic indices of indolent lymphomas.
→ hematologist

MDT talk tree (2 steps)

#	Owner	Topic	Action
1	hematologist	Staging / disease burden	What is the current LDH? Marker of tumor burden and transformation.
2	clinical_pharmacist	Specialist review	Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.

Skills (recommended) — for consideration (1)

Clinical pharmacist recommended
Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.

Data quality

Usable with caveats. No critical default-track gap was found, but the MDT should review the listed caveats before final sign-off.

Biomarker coverage: 0/0 known (100%), 0 missing, 0 default-track gaps
Unevaluated RedFlags: RF-ACHALASIA-ESOPHAGEAL-PREVENTION, RF-ACTIVE-AUTOIMMUNE-DISEASE-ICI-RISK, RF-BARRETTS-ESOPHAGUS-PREVENTION, RF-ESOPH-FRAILTY-AGE, RF-ESOPH-INFECTION-SCREENING, RF-ESOPH-SEVERE-DYSPHAGIA-ASPIRATION, RF-ESOPH-TRANSFORMATION-PROGRESSION, RF-ESOPHAGEAL-POST-CROSS-NON-PCR, RF-LIFESTYLE-ALCOHOL-CANCER-PREVENTION, RF-LIFESTYLE-HOT-BEVERAGES-PREVENTION, RF-LIFESTYLE-HOT-MATE-ESOPHAGEAL-PREVENTION, RF-LIFESTYLE-OBESITY-CANCER-PREVENTION, RF-LIFESTYLE-SMOKELESS-TOBACCO-PREVENTION, RF-OLIGOMET-DEFINITION

Technical MDT skill metadata (1/16 activated in this plan)

All registered virtual specialists. ✓ — activated for this case; ○ — not activated (available for other clinical scenarios).

Specialist	skill_id	Version	Last reviewed	Domain
Cellular therapy specialist (CAR-T)	`cellular_therapy_specialist`	v0.1.0	2026-04-25	cellular_therapy
Clinical pharmacist	`clinical_pharmacist`	v0.1.0	2026-04-25	clinical_pharmacy
Hematologist / oncohematologist	`hematologist`	v0.1.0	2026-04-25	hematology_oncology
Hematopathologist (lymphoma / leukemia / myeloma)	`hematopathologist`	v0.1.0	2026-04-25	hematopathology
Infectious disease / hepatology	`infectious_disease_hepatology`	v0.1.0	2026-04-25	infectious_diseases
Medical oncologist (solid-tumor chemotherapist)	`medical_oncologist`	v0.1.0	2026-04-25	solid_oncology
Molecular geneticist / molecular oncologist	`molecular_geneticist`	v0.1.0	2026-04-25	molecular_oncology
Palliative care	`palliative_care`	v0.1.0	2026-04-25	palliative_care
Pathologist (general)	`pathologist`	v0.1.0	2026-04-25	pathology
Primary care / family physician	`primary_care`	v0.1.0	2026-04-25	primary_care
Psycho-oncologist	`psychologist`	v0.1.0	2026-04-25	psychosocial
Radiation oncologist	`radiation_oncologist`	v0.1.0	2026-04-25	radiation_oncology
Radiologist	`radiologist`	v0.1.0	2026-04-25	diagnostic_imaging
Social worker / case manager	`social_worker_case_manager`	v0.1.0	2026-04-25	psychosocial
Surgical oncologist	`surgical_oncologist`	v0.1.0	2026-04-25	surgical_oncology
Transplant specialist (BMT)	`transplant_specialist`	v0.1.0	2026-04-25	cellular_therapy

Sources cited

SRC-ESMO-ESOPHAGEAL-2024: ESMO Esophageal Cancer (2024)
SRC-NCCN-ESOPHAGEAL-2025: NCCN Esophageal and EGJ Cancers (v.3.2025)

Experimental options (clinical trials)

Third plan track — open-enrollment trials from ClinicalTrials.gov. Render-time metadata; engine selection is not affected by this block (CHARTER §8.3). Last synced: 2026-08-17.

NCT	Title	Phase	Status	Sponsor	UA	Signals
NCT06476678	Novel Bipolar Radiofrequency Ablation Knife in Esophageal Lesions	N/A	RECRUITING	Baylor College of Medicine	—	Single country
NCT05412758	Augmented Response of Volatile Biomarkers in Assessment of Oesophagogastric Cancer (AROMA 1 / BIORESOURCE)	NA	RECRUITING	Imperial College London	—	Single country
NCT06172478	A Study of HER3-DXd in Subjects With Locally Advanced or Metastatic Solid Tumors	PHASE2	RECRUITING	Daiichi Sankyo	—	Surrogate endpoint only
NCT07749586	A Study to Evaluate ARV-6723 Alone and With Pembrolizumab in Participants With Advanced Solid Tumors	PHASE1 / PHASE2	RECRUITING	Arvinas Inc.	—	Surrogate endpoint only Single country
NCT06232083	A Multi Tumor, Open Phase I Clinical Study on the Progression of First-line Anti-tumor Therapy Using Cardonizumab Combined With Pulsed Low-dose Rate External Irradiation (PLDR)	PHASE1	RECRUITING	Anhui Provincial Hospital	—	Phase 1 only Small N (<50) Surrogate endpoint only Single country
NCT07266480	Clinical Study of Adbelimumab in the Adjuvant Treatment of Esophageal Squamous Cell Carcinoma.	PHASE2	RECRUITING	Hebei Medical University Fourth Hospital	—	Surrogate endpoint only Single country
NCT06181656	Serologic Response to Pneumococcal Vaccination Among Esophageal Cancer Patients With High Grade Lymphopenia After Chemoradiation	N/A	RECRUITING	M.D. Anderson Cancer Center	—	Single country
NCT03961945	Minimally Invasive Molecular Approaches for the Diagnosis of Barrett's Esophagus and Esophageal Adenocarcinoma	NA	RECRUITING	Mayo Clinic	—	Single country
NCT04519905	Phase III Study of Concurrent Radiotherapy in Elderly Patients With Esophageal Squamous Cell Carcinoma (ESO-Shanghai 15)	NA	RECRUITING	Fudan University	—	Single country
NCT07188103	Ivonescimab Plus Short-Course Hypofractionated Radiotherapy as Second-Line Therapy for Esophageal Squamous Cell Carcinoma	PHASE2	RECRUITING	Anhui Provincial Hospital	—	Small N (<50) Surrogate endpoint only Single country

Verify recruitment status directly with the trial site. ctgov data can lag behind current UA-site status.

Option availability in Ukraine

Per-track UA registration · NSZU · cost · access pathway. Render-time metadata; engine selection does not depend on these fields (CHARTER §8.3).

Option	UA registration	NSZU	Cost orientation	Access pathway
Aggressive plan Nivolumab adjuvant — post-CROSS without pCR (CheckMate-577) (REG-NIVO-ADJUVANT-ESOPH)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Standard plan Weekly carboplatin + paclitaxel (CROSS-style chemo backbone) (REG-CARBOPLATIN-PACLITAXEL-WEEKLY)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Trial · NCT06476678 Novel Bipolar Radiofrequency Ablation Knife in Esophageal Lesions No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT05412758 Augmented Response of Volatile Biomarkers in Assessment of Oesophagogastric Cancer (AROMA 1 / BIORESOURCE) No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06172478 A Study of HER3-DXd in Subjects With Locally Advanced or Metastatic Solid Tumors No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07749586 A Study to Evaluate ARV-6723 Alone and With Pembrolizumab in Participants With Advanced Solid Tumors No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06232083 A Multi Tumor, Open Phase I Clinical Study on the Progression of First-line Anti-tumor Therapy Using Cardonizumab Combined With Pulsed Low-dose Rate External Irradiation (PLDR) No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07266480 Clinical Study of Adbelimumab in the Adjuvant Treatment of Esophageal Squamous Cell Carcinoma. No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06181656 Serologic Response to Pneumococcal Vaccination Among Esophageal Cancer Patients With High Grade Lymphopenia After Chemoradiation No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT03961945 Minimally Invasive Molecular Approaches for the Diagnosis of Barrett's Esophagus and Esophageal Adenocarcinoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT04519905 Phase III Study of Concurrent Radiotherapy in Elderly Patients With Esophageal Squamous Cell Carcinoma (ESO-Shanghai 15) No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07188103 Ivonescimab Plus Short-Course Hypofractionated Radiotherapy as Second-Line Therapy for Esophageal Squamous Cell Carcinoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor

Cost information is orientation. Verify with a specific pharmacy / foundation / trial site. Status updated: 2026-08-17.

plan_id: PLAN-ESOPH-CROSS-CM577-001-V1 | version: 1 | generated: 2026-08-17T08:06:31.299917+00:00

Per FDA non-device CDS positioning (CHARTER §15): Outpatient oncology treatment planning to support tumor-board discussion. Not a medical device; not for autonomous clinical decision-making.

Per FDA non-device CDS positioning (CHARTER §15): Both treatment options below are presented for review. The engine's selection of a 'recommended' default does not constitute a clinical decision. Final treatment selection requires HCP judgment incorporating information not available to the system.

This document is an informational resource supporting tumor-board discussion (per CHARTER §11). It is not a system that makes clinical decisions. Every recommendation must be verified by the treating physician.