Teaching Presentation

Esophageal Cancer
Megan Comer
 General information
 Male
 70 y/o
 Stage IIB (uT3, N0, cM0) of the distal esophagus/GE
junction.
 What do you think is the pathology?
 Family and Social History
 Family history:
 Aneurysm at 22 y/o in his brother
 Breast Cancer in his maternal aunt
 Prostate Cancer in his brother and father
 He reports that he has never smoked, never used
smokeless tobacco, never used illicit drugs and does
not drink alcohol
 Medical History
 Arthritis
 Cellulitis
 Charcot-Marie-Tooth disease
 Goiter
 Hypothyroid
 Melanoma (2006)
 Melanoma in situ of other parts of face (5/19/2016)
 OSA (obstructive sleep apnea)
 Sepsis
 Surgical History
 Tonsillectomy
 Joint replacement (Left side, 03/2012) (Right side, 12/2012);
 Mohs surgery (2007)
 Thyroidectomy
 Cholecystectomy
 Cataract removal (Left side 2/29/2016) (Right side 3/14/2016)
 Appendectomy (10/7/2014)
 Hernia repair (8/11/2014)
 Colonoscopy diagnostic (3/19/2012)

 Wide excision of melanoma (03/19/2016)

 Ultrasound guided needle aspiration (2/22/2017)

 Epidemiology
 16,940 new cases diagnosed in 2017
 13,360 men and 3,580 women)

 15,690 deaths in 2017

 12,720 men and 2,970 women

 4 times more common in men than women

 Slightly more common in Caucasians than other races
 Adenocarcinoma most common histology for Caucasians
 Squamous cell carcinomas more common in African Americans
 Etiology
 No sure cause of esophageal adenocarcinoma
 Risk factors:
 GERD, Barrett’s esophagus
 Smoking
 Obesity
 Drinking alcohol
 Drinking hot liquids often
 Not eating enough fruits and vegetables
 Anything that chronically irritates the esophagus
Anatomy Review
Anatomy Review
Anatomy Review
 Lymphatics
 Extensive network of lymphatics in submucosal layer of esophagus,
causes easy nodal spread

 Proximal esophagus:
 Deep cervical
 Superior paraesophageal

 Middle esophagus:
 Superior, posterior mediastinal
 Hilar
 Subcarinal
 Inferior paraesophageal

 Distal esophagus:
 Left gastric
 Celiac
 Staging - T
 T0: No evidence of primary tumor.
 Tis: Evidence of cancer only in epithelium.
 T1a: The cancer has grown into the lamina propris or
muscularis mucosa
 T1b: The cancer has grown into the submucosa
 T2: The cancer has grown into the muscularis propria
 T3: The cancer has grown into the adventitia
 T4a: The cancer has grown into the pleura, the pericardium,
or the diaphragm.
 T4b: The cancer has grown into the trachea, aorta, spine or
other crucial structures
 Staging - N
 Nx: No description of lymph node involvement possible
due to lack of information

 N0: No lymph node spread

 N1: The cancer has spread to 1 or 2 nearby nodes
 N2: The cancer has spread to 3 to 6 nearby nodes
 N3: The cancer has spread to 7 or more nearby nodes
 Staging - M
 M0: The cancer has not metastasized to distant
organs or lymph nodes

 M1: The cancer has spread to distant lymph nodes and

or other organs
 What are common met sites?
 Grading
 G1: well differentiated
 G2: moderately differentiated
 G3: poorly differentiated
 G4: undifferentiated
Stage IIB: Either of the following:

T3, N0, M0, any G: The cancer has grown through the wall of the
esophagus to its outer layer, the adventitia (T3). It has not spread to
nearby lymph nodes (N0) or to distant sites (M0). It can be any grade.

T1 or T2, N1, M0, any G: The cancer has grown into the layers below the
epithelium, such as the lamina propria, muscularis mucosa, or
submucosa (T1). It may also have grown into the muscularis propria (T2).
It has not grown through to the outer layer of tissue covering the
esophagus. It has spread to 1 or 2 lymph nodes near the esophagus
(N1), but it has not spread to lymph nodes farther away from the
esophagus or to distant sites (M0). It can be any grade.
 Presenting signs and
symptoms
 Pt presented to doctors office with persistent epigastric
pain and dysphagia
 Reported about 40 lbs weight loss over the course of 3
months prior

 PET/CT performed, diagnosis made

Pre Treatment PET/CT
Pre Treatment PET/CT
 Treatments
 Concurrent chemoradiation
 5040 cGy of radiation therapy
 Xeloda
 Esophagectomy – planned for post chemoradiation
 Chemotherapy
 Treated with Xeloda
 Paclitaxel more common treatment, but contraindicated
due to Charcot-Marie-Tooth disease
 Can cause neurotoxicities due to platinum
 Want to avoid this at all cost since patient is already
dealing with neurologic issues

 After diagnosis of advanced nodal disease following

chemoradiation, patient was put on FOLFIRI palliative
chemotherapy regimen
 Surgical treatment
 Trimodal treatment was recommended at diagnosis
 Cycle of chemoradiation followed by more systemic
therapies

 After recent PET/CT showed advanced nodal disease,

esophagectomy no longer a curative option
 “Cancers that have grown into nearby structures or that
have spread to distant lymph nodes or to other organs
are considered unresectable, so treatments other than
surgery are usually the best option.”
 RT Treatment Plan
 Prescription: 4500 cGy with 540 cGy boost. 25 fx, 3 fx
boost

 Machine energy: 6 MV, 2 VMAT arcs (for tx and boost)

 CBCT first three days then 2x week. line up to spine,

aorta, PTV
 Set Up
 Supine
 DoseMax board
 Arm Shuttle
 B HR at 12/16
 Hands grasping D/F
 Upper vac-lock
 Knee sponge, indexed
 Organs at risk
 Kidneys – 2300 cGy

 Lungs – 1750 cGy

 Spine – 4700 cGy for 20 cm

 Liver – 3000 cGy

 Heart – 4000 cGy

 Small bowel – 4000 cGy

 Stomach – 5000 cGy

Red PTV 45 Green PTV 50.4
 Side effects
 Short term:
 Skin reaction such as dryness, redness and itchiness
 Fatigue
 Sore throat, esophagitis, pneumonitis
 Loss of appetite, nausea, weakness, anorexia
 GERD
 Painful sores in mouth and throat

 Long term:
 Esophageal strictures
 Spinal cord damage
 Pulmonary fibrosis that may worsen lung function
 Side effect treatments
 Esophagitis:
 Proton pump inhibitor, H2 blocker, and Magic mouthwash
 Anorexia:
 Small meals, liquid nutritional supplements, soft and easy to
digest foods

 Nausea:
 Compazine, Zofran
 Pain:
 Oxycodone
 GERD
 Pantoprazole
 Prognosis and survival
 Overall 5 year survival rate is 18%

Stage 5-Year Relative Survival

Rate
Localized 43%
Regional 23%
Distant 5%
 References
 Survival Rates for Esophageal Cancer by Stage. www.cancer.org.
https://www.cancer.org/cancer/esophagus-cancer/detection-
diagnosis-staging/survival-rates.html. Published June 14, 2017.
Accessed September 27, 2017.
 Esophageal Cancer: Statistics. www.cancer.net.
http://www.cancer.net/cancer-types/esophageal-cancer/statistics.
Published December 2016. Accessed September 27, 2017.
 Esophageal Cancer Stages. www.cancer.org.
https://www.cancer.org/cancer/esophagus-cancer/detection-
diagnosis-staging/staging.html. Published June 14, 2017.
Accessed September 27, 2017.
 Hackworth, Ruth. Esophageal Cancer Presentation. Fall 2016.