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KC Esophageal CA case study
- 1. 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
- 2. CONFIDENTIAL AND PROPRIETARY © 2014 Sarah Cannon. 2
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”
- 3. CONFIDENTIAL AND PROPRIETARY © 2014 Sarah Cannon. 3
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
- 7. CONFIDENTIAL AND PROPRIETARY © 2014 Sarah Cannon. 7
PATIENT PRESENTATION CONT.
1/16/15 Underwent endoscopy that showed mass in distal esophagus
Biopsy revealed poorly differentiated adenocarcinoma with singet ring cells
- 8. CONFIDENTIAL AND PROPRIETARY © 2014 Sarah Cannon. 8
1/16/15 EGD BIOPSY PATHOLOGY
Poorly differentiated
adenocarcinoma with signet ring
cells
- 9. CONFIDENTIAL AND PROPRIETARY © 2014 Sarah Cannon. 9
1/16/15 EGD BIOPSY PATHOLOGY
Poorly differentiated
adenocarcinoma with signet ring
cells
- 10. CONFIDENTIAL AND PROPRIETARY © 2014 Sarah Cannon. 10
PATIENT PRESENTATION CONT.
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
- 14. CONFIDENTIAL AND PROPRIETARY © 2014 Sarah Cannon. 14
PATIENT PRESENTATION CONT.
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
- 17. CONFIDENTIAL AND PROPRIETARY © 2014 Sarah Cannon. 17
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)
- 18. CONFIDENTIAL AND PROPRIETARY © 2014 Sarah Cannon. 18
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
- 22. CONFIDENTIAL AND PROPRIETARY © 2014 Sarah Cannon. 22
SURGICAL APPROACH
4/16/15 Transhiatal esophagogastrectomy with gastric pull up and cervical
esophagogastrostomy performed by Dr. Cates.
- 23. CONFIDENTIAL AND PROPRIETARY © 2014 Sarah Cannon. 23
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
- 24. CONFIDENTIAL AND PROPRIETARY © 2014 Sarah Cannon. 24
4/17/15 ESOPHAGOGASTRECTOMY SPECIMEN PATHOLOGY
Residual poorly differentiated
adenocarcinoma
- 25. CONFIDENTIAL AND PROPRIETARY © 2014 Sarah Cannon. 25
4/17/15 ESOPHAGOGASTRECTOMY SPECIMEN PATHOLOGY
Rare isolated tumor cells in 1 of 18
lymph nodes