Aruna Yera - Oncology Report Summary & Comparison

1. Biopsy - 3 March 2026 (Baseline / Diagnostic)

• Specimen: Biopsy from esophageal lesion at 25 cm from incisor tooth
• Gross: Two gray-white tissue fragments, 0.6 cm
• Microscopy: Stratified squamous epithelium with severe dysplasia to carcinoma-in-situ; pleomorphic, hyperchromatic nuclei with prominent nucleoli; high N:C ratio; foci of tumor infiltration into subepithelial tissue; lymphocytic stromal infiltration
• Impression: Superficially invasive squamous cell carcinoma

2. PDL-1 Testing - 11 March 2026 (Biomarker for Immunotherapy)

• Material: Paraffin block (194/26) - the same biopsy block from March 3
• Method: PD-L1 IHC 22C3 (Dako Agilent) on Dako AS Link 48 platform
• Result: CPS (Combined Positive Score) = approximately 10
• Interpretation: CPS ≥10 is the recommended positive cut-off for esophageal squamous carcinoma - Aruna's tumor is PD-L1 positive at the threshold
• Significance: This makes her eligible for anti-PD-1/PD-L1 immunotherapy (e.g., pembrolizumab/nivolumab) in combination with chemotherapy

3. PET-CT Scan - 5 March 2026 (Baseline Staging)

4. PET-CT Scan - 7 May 2026 (Post-Chemotherapy Response Assessment)

5. Endoscopy - 12 May 2026 (Post-Treatment Structural Assessment)

• Indication: Dysphagia
• Finding at 25 cm: Unhealthy mucosa present; no friability or obvious growth seen
• Key observation: Regression in size noted compared to earlier findings
• Limitation: Scope could not be negotiated further due to stricture/narrowing
• Impression: Descriptive (no new biopsy taken)

Overall Clinical Picture

Treatment Response Summary

Key Points

1. The response to chemotherapy is substantial - the primary tumor has shrunk dramatically in length (~85%) and metabolic activity has dropped by ~64%. This qualifies as a partial response by PET-CT criteria (PERCIST).
2. PD-L1 CPS = 10 at baseline means Aruna is eligible for immunotherapy (pembrolizumab is FDA/approved for esophageal SCC with CPS ≥10). This opens an important therapeutic option going forward.
3. A stricture remains at 25 cm on endoscopy - the scope could not pass, and she still has dysphagia. This indicates residual disease or post-treatment fibrosis and may require dilation or further treatment.
4. Nodal disease has completely cleared on PET - both the supraclavicular and hepatogastric nodes are metabolically inactive.
5. No distant metastases have appeared - the disease remains loco-regional throughout.
6. Important next steps typically considered in such cases include: reassessment for surgery (esophagectomy) or chemoradiation, consideration of adding immunotherapy (pembrolizumab + chemotherapy, per KEYNOTE-590 data), and endoscopic dilation for dysphagia relief.

Disclaimer: This is an educational summary of medical reports. All clinical decisions must be made by Aruna's treating oncologist based on her full clinical picture.

1. Timeline ribbon - The chronological journey from biopsy (3 Mar) → baseline PET (5 Mar) → PD-L1 test (11 Mar) → chemotherapy → response PET (7 May) → endoscopy (12 May)
2. Primary tumor bar chart - Side-by-side before/after for all three tumor metrics with reduction percentages highlighted in gold: SUV -64%, tumor length -85%, wall thickness -45%
3. Lymph node response - Bubble visualization showing both nodes (left supraclavicular and hepatogastric) went from FDG-avid (SUV 2.2/2.4) to completely undetectable
4. Biomarker & Endoscopy panel - PD-L1 CPS=10 positive status with immunotherapy eligibility note, plus the endoscopy findings (regression confirmed but stricture present)
5. Overall assessment banner - Four summary cards showing the PERCIST partial response across all dimensions

• She had a strong partial response to chemotherapy before surgery - the tumor shrank from 6.7 cm to ~10 mm and SUV dropped from 15.6 to 5.6
• Both lymph nodes had completely cleared on the pre-op PET scan
• No distant metastases were ever detected

• ICU/hospital stay of 7-14 days
• Gradual return to oral feeding (liquids → soft diet → normal)
• Pathology of the resected specimen to confirm margins and residual tumor burden (ypT/ypN staging)
• Given her PD-L1 CPS = 10, her oncologist may consider adjuvant immunotherapy (nivolumab is approved post-surgery for esophageal SCC per CheckMate-577 data)
• Regular surveillance PET/CT and endoscopy follow-up

What "1 lymph node positive" means

Is this serious?

• It was only 1 node - the fewer nodes involved, the better the prognosis
• The primary tumor had responded very well to chemo (85% shrinkage) - that is favorable
• The left supraclavicular and hepatogastric nodes had completely cleared on PET - so the disease responded overall, with this one node being a residual focus
• She had the surgery - the involved node was physically removed along with the specimen, so it is no longer in her body

Why this matters going forward

In summary

Nivolumab — What is it?

How does it work — in simple language

Cancer cell           T-cell (immune fighter)
   [PD-L1] ──────→  [PD-1]   ← Nivolumab BLOCKS this
   "Don't kill me"     "OK, I'll ignore you"
                          ↓ with nivolumab
                       "I CAN see you — attack!"

Why is it relevant for Aruna specifically?

1. She had residual disease after chemo (1 positive lymph node) — this is exactly the patient population CheckMate-577 trial enrolled
2. Her PD-L1 CPS = 10 — her tumor expresses PD-L1, meaning nivolumab has a "signal" to work against
3. Her cancer type is esophageal SCC — nivolumab is approved specifically for this

What did the CheckMate-577 trial show?

• Patients: esophageal cancer, had chemo + surgery, had residual disease in the specimen
• Result: Nivolumab doubled disease-free survival (22 months vs 11 months vs placebo)
• Meaning: patients on nivolumab went twice as long without the cancer coming back

Side effects — what to expect

Bottom line for Aruna

Surgery removed the cancer. Nivolumab for 12 months after surgery is like a "security patrol" — keeping the immune system alert to catch and destroy any stray cancer cells that might try to return. Given her 1 positive node, this is a meaningful risk-reduction step.