KC Esophageal CA case study

CONFIDENTIAL AND PROPRIETARY © 2014 Sarah Cannon. 1
NEOADJUVANT TREATMENT
APPROACH TO ESOPHAGEAL
CANCER
DR. JOE CATES
DR. SYED JAFRI
DR. KAIDI MIKHITARIAN
DR. FRANK SLOVICK

PATIENT R.S.
57 year old male
Past Medical History:
 GERD (requiring ~5 esophageal dilations over 20 years)
 Hiatal hernia
 ETOH use (<7 drinks per week)
 BPH
Past Surgical History:
 Appendectomy (August/2009)
 Labrum/rotator cuff repair (July/1989)
 Hernia repair as a child
Family History:
 Maternal grandmother-CRC
 Father- “some kind of leukemia”

PATIENT PRESENTATION
R.S. had endoscopy with esophageal dilation in early December 2014 due to
increasing dysphagia
 Informed that there were no masses/obstructions
 Developed worsening dysphagia within a few days post endoscopy, PCP ordered
upper GI series which revealed esophageal stricture
1/16/15 CT of the Chest, Abdomen and Pelvis
 Revealed asymmetric thickening of the lower esophagus and/or GE junction, with
asymmetry along the outer surface of the esophagus posterolaterally to the left

1/16/15 CT CHEST/ ABDOMEN/ PELVIS (PRE-NEOADJUVANT THERAPY)

PATIENT PRESENTATION CONT.
1/16/15 Underwent endoscopy that showed mass in distal esophagus
 Biopsy revealed poorly differentiated adenocarcinoma with singet ring cells

1/16/15 EGD BIOPSY PATHOLOGY
Poorly differentiated
adenocarcinoma with signet ring
cells

1/23/15 Underwent EUS with FNA and stent placement
 Revealed malignant-appearing esophageal stricture measuring 2 cm in length x 4 mm
inner diameter
 Mass in the gastroesophageal junction measuring up to 10 mm in thickness
 Three malignant lymph nodes in the middle paraesophageal mediastinum (level 8M)
 EUS Stage T3 N1 M0

1/23/15 MEDIASTINAL LYMPH NODE, FNA
Positive for adenocarcinoma

2/5/15 PET/ CT scan revealed activity in the following:
 Mass in distal third of esophagus
 At the proximal and distal ends of the esophageal stent
 Mediastinal lymphadenopathy

2/5/15 PET/ CT (PRE-NEOADJUVANT THERAPY)

NEOADJUVANT APPROACH FOR R.S.
Based on EUS staging, pathology and imaging, R.S. was determined to be
Stage III and it was decided to place him on neoadjuvant concurrent
radiation and chemotherapy
 2/11/15: Started concurrent chemotherapy/XRT with weekly Carboplatin AUC 2 and
Taxol
 3/11/15: Stopped chemotherapy (5 cycles completed)
 3/17/15: Ended radiation treatment (25 fractions completed)

RE-STAGING FOR R.S.
3/26/15: CT revealed:
 Esophageal malignancy traversed by a stent, uncertain as to the extent of the
malignancy, which may extend into the proximal stomach.
 Soft tissue mass causes marked narrowing of the proximal end of the stent
 Mediastinal adenopathy with indeterminate splenic lesions
 Small node anterior to the left adrenal gland

3/26/15 CT POST-NEOADJUVANT THERAPY

SURGICAL APPROACH
4/16/15 Transhiatal esophagogastrectomy with gastric pull up and cervical
esophagogastrostomy performed by Dr. Cates.

DIAGNOSIS
Surgical pathology:
 Primary Tumor site: Esophagogastric junction (EGJ)
 Additional sites involved by tumor: none identified
 Histologic type: Adenocarcinoma
 Histologic grade: G3 – poorly differentiated
 Tumor size: greatest dimension 2.2 cm
 Microscopic tumor extension: tumor invades through the muscularis propria into the
periesophageal soft tissue (adventitia)
 Margins: all margins uninvolved by invasive carcinoma; distance of invasive carcinoma
from closest margin 2 mm
 Treatment effect: present, marked response (grade 1, minimal residual cancer)
 Regional lymph nodes: 1 involved out of 18 examined
 Stage: T3 N1 M0

4/17/15 ESOPHAGOGASTRECTOMY SPECIMEN PATHOLOGY
Residual poorly differentiated
adenocarcinoma

4/17/15 ESOPHAGOGASTRECTOMY SPECIMEN PATHOLOGY
Rare isolated tumor cells in 1 of 18
lymph nodes

ADJUVANT TREATMENT
• Open for discussion ………….

KC Esophageal CA case study

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