Patient Privacy Patient Privacy Issues Name Class Date Professor Patient Privacy Issues New technology has brought many benefits to the healthcare industry but it has also resulted in challenges involving keeping patient information private and confidential. As more and more healthcare facilities go digital the threat of the private patient record going public is an alarming problem. Not only do patients risk someone hacking into their private patient file there is also the risk of their information being sold. Patient privacy is no longer as secure as it was in the past with the written record. Keeping a patients record from being accessed requires the healthcare facility to take steps to properly secure this information. Even then this private information is at risk from internal and external sources at the healthcare facility. One situation where the private information of the patient becomes vulnerable is a case where an employee sold patients private information for illegal gains. An employee at Howard University Hospital named Laurie Napier used her position as a hospital tech to access private hospital records and to sell them to criminals so they could be used for criminal purposes (Shultz, 2012). In this situation the employee was caught selling the private information of patients. This private information includes name, address, birth date, Medicare health numbers, and social security number. This private information can be used by criminals to create fraudulent accounts, open credit cards, and create new identities. The employee was able to steal the private information of tens of thousands of patients because the patient files were password protected but the information was not encrypted to prevent theft. Not only did patients become vulnerable to fraud, the reputation of the healthcare facility also becomes damaged due to their inability to protect patient records. As a result of the illegal actions of Napier she was charged under the HIPPA law. The Health Insurance Portability and Accountability Act (HIPPA) privacy rule ensures the healthcare facility does not release the private information of the patient without their express permission. The Privacy Rule is balanced so that it permits the disclosure of health information needed for patient care and other important purposes but also ensure this information is held in confidence (DHS, 2015). The Security Rule defines the necessary security safeguards required to be put into place by the healthcare facility, business associates, and healthcare clearinghouses that share patient’s healthcare information. When Laurie Napier stole the private information of over 34,000 patients she violated the privacy rights of the patients and broke the law. Her violation was criminal but they hospital was also at fault due to their failure to protect private patient information. Prior to the Napier theft the hospital had a previous situation where another employee.

1. Patient Privacy
Patient Privacy Issues
Name
Class
Date
Professor
Patient Privacy Issues
New technology has brought many benefits to the healthcare
industry but it has also resulted in challenges involving keeping
patient information private and confidential. As more and more
healthcare facilities go digital the threat of the private patient
record going public is an alarming problem. Not only do
patients risk someone hacking into their private patient file

2. there is also the risk of their information being sold. Patient
privacy is no longer as secure as it was in the past with the
written record. Keeping a patients record from being accessed
requires the healthcare facility to take steps to properly secure
this information. Even then this private information is at risk
from internal and external sources at the healthcare facility.
One situation where the private information of the patient
becomes vulnerable is a case where an employee sold patients
private information for illegal gains. An employee at Howard
University Hospital named Laurie Napier used her position as a
hospital tech to access private hospital records and to sell them
to criminals so they could be used for criminal purposes
(Shultz, 2012). In this situation the employee was caught selling
the private information of patients. This private information
includes name, address, birth date, Medicare health numbers,
and social security number. This private information can be
used by criminals to create fraudulent accounts, open credit
cards, and create new identities.
The employee was able to steal the private information of tens
of thousands of patients because the patient files were password
protected but the information was not encrypted to prevent
theft. Not only did patients become vulnerable to fraud, the
reputation of the healthcare facility also becomes damaged due
to their inability to protect patient records. As a result of the
illegal actions of Napier she was charged under the HIPPA law.
The Health Insurance Portability and Accountability Act
(HIPPA) privacy rule ensures the healthcare facility does not
release the private information of the patient without their
express permission.
The Privacy Rule is balanced so that it permits the disclosure of
health information needed for patient care and other important
purposes but also ensure this information is held in confidence
(DHS, 2015). The Security Rule defines the necessary security
safeguards required to be put into place by the healthcare
facility, business associates, and healthcare clearinghouses that
share patient’s healthcare information. When Laurie Napier

3. stole the private information of over 34,000 patients she
violated the privacy rights of the patients and broke the law.
Her violation was criminal but they hospital was also at fault
due to their failure to protect private patient information.
Prior to the Napier theft the hospital had a previous situation
where another employee downloaded patient files in order to
sell them. Under federal law Napier was charged with wrongful
disclosure of patients’ individually identifiable health
information. Because she yielded less than $5,000 dollars for
her crime she received house arrest with three years probation.
Napier is responsible for paying a fine of $2,100 dollar fine and
will have to complete 100 hours of community service (Narasi,
2012). Before she can go on house arrest Napier must first six
months in a halfway house.
Hospitals are considered covered entities under the HIPPA. All
covered entities are responsible for taking the necessary steps to
protect the patient’s private information. This includes taking
steps to block the information from being stolen electronically.
While Howard University Hospital placed password protection
on patient files it was not sufficient to stop employees from
stealing the information and selling it to others. When the first
theft occurred by an employee the hospital should have taken
immediate steps to rectify the security issues. If the hospital
had simply placed encryption software on hospital computers
any stolen information would have been unreadable.
While the employee is responsible for her illegal behavior she
took advantage of an opportunity to steal information that was
not properly protected. If the hospital had the proper protections
in place the two breaches would never have occurred. New
reporting rules require that the healthcare facility warn the
patient, the public, and the media of the breach. Because the
healthcare agency is required by law to report these breaches
there has been a growing number of cases were the private
records of the patient are breached. In November of last years
the countries larges data breach in the healthcare industry when
thieves stole the private information of five million patients of

4. TRICARE, a military healthcare insurance agency.
According to an HHS database, more than 40 percent of medical
data breaches in the past two and a half years involved portable
media devices such as laptops or hard drives (Shultz, 2012).In
the Napier case and the case earlier in the year a laptop was
used in order to obtain the private information. When private
information is accessed through a third party device it increases
the security risk especially when the private data is not
encrypted.
If Howard University Hospital was in full compliance with
HIPPA the security breach would have been prevented but the
hospital was not in full compliance of the law. HIPPA requires
that health care entities, under the Security Rule, apply
administrative, physical, and technical safeguards to ensure the
private information of the patient is secure. By failing to protect
this information the company is vulnerable to private
information being lost. When this happens patients have the
right to sue the hospital for their failure to protect patient
privacy. In response to the two security breaches the
administration of the hospital claimed they were taking steps to
fix the problem.
Healthcare facilities have an ethical duty to their patients that
includes upholding their privacy. When Howard University
Hospital failed to take the steps to protect the patients they
failed in their ethical duty. If a healthcare organization fails to
displays the ethical behavior expected of them it can result in
damage to the reputation of the hospital and result in a loss of
trust by patients. Healthcare organizations have other ethical
duties to the patient but making sure the confidentiality of the
patient is upheld is an important one especially in the 21st
century. When a patient’s private information is not properly
secured it becomes vulnerable to security threats. The Howard
University Hospital has a legal and ethical duty to properly
secure the patients private information.
In order to prevent security breaches in the healthcare setting
the same level of security applied to financial sector should be

5. applied to the healthcare industry. The financial sector has long
recognized the need to develop a comprehensive, multi-tiered,
security plan that will ensure no avenue is left open for the
criminal to breach the private data of the hospital. This begins
with conducting an assessment to identify security
vulnerabilities and then developing a plan to address the
vulnerabilities. In the case of Howard University Hospital the
hospital failed to recognize the vulnerability associated with not
using encryption software to protect employee files and the
vulnerabilities associated with the use of third party devices
accessing sensitive hospital data.
The first step is to place encryption software on all hospital
data and to add additional layers of security. This would include
placing computers servers in a secure location that can only be
accessed by personnel with the authority to access the sensitive
data. When too many people have access to passwords and
computer servers it can create security breaches. Lastly the
hospital needs to restrict the use of third party devices to access
sensitive hospital data unless the device is assigned by the
hospital after it has been properly secured.
The healthcare industry is changing. It is no longer a simple
matter to keep track of patient information in patient files that
could simply be locked up. With new electronic patient files the
healthcare industry has no choice but to enter the 21st Century
and make sure that patient information is properly protected.
This means restricting access to patient files and putting the
proper security measures in place. The Howard University
Hospital was negligent when they failed to properly secure
patient files especially after the first incident. In order to ensure
security breaches like the one committed by Napier do not
happen again the hospital needs to be in compliance with
HIPPA and establish a more effective security approach to
protecting patient information.

6. References
Narasi, S. (2012). Hospital employee sold 40 patients’ protected
health information. Retrieved
January 23, 2015 from
http://www.healthcarebusinesstech.com/hospital-employee-sold-
40-
patients-protected-health-information/
Shultz, D. (2012). As Patients’ Records Go Digital, Theft And
Hacking Problems Grow. Kaiser
New Health. Retrieved January 23, 2015 from
http://kaiserhealthnews.org/news/electronic-
health-records-theft-hacking/
U.S. Department of Health & Human Services. (2015).
Understanding Health Information
Privacy. Retrieved January 23, 2015 from
http://www.hhs.gov/ocr/privacy/hipaa/understanding/
Radiation Technique for Esophagus Cancer
The more recent RTOG esophagus protocol (RTOG 0436)
combined Erbitux, Taxol,
cisplatin plus 50Gy uses the techniques here and here.
When the dose is pushed over 5000cGy then a technique similar
to RTOG 94-05 would
be used:
Initial Course (50.4 Gy) Target Volume: RT will begin on the
first day of week 1. The
superior and inferior borders of the field will be 5 cm beyond

7. the tumor and the lateral
borders of the field will be 2 cm beyond the lateral borders of
the tumor as defined by
endoscopic U/S, esophagram, or CT (whichever is larger). The
peri-esophageal nodes
will be included. A barium swallow will also be obtained at the
time of simulation to
confirm the location of the esophagus. If the primary tumor is
above the carina (proximal
esophagus), the supraclavicular nodes will be included in the
initial (50.4 Gy) RT field. A
localized photon or electron boost to the supraclavicular fossa
(SCF) is allowed if the
SCF dose is < 50.4 Gy (specified at 3 cm depth from the
anterior skin surface). The
daily fraction size will be 1.8 Gy/day x 28 fractions.
Cone-Down (14.4 Gy) Target Volume: will be performed in a
similar manner, however,
the superior and inferior field will be decreased to 2 cm beyond
the tumor. The lateral
field will remain 2 cm beyond the lateral borders of the tumor
as defined by CT or
esophageal U/S, whichever is larger. A dose of 14.4 Gy (1.8 Gy
x 8 fractions) will be
delivered. The maximum dose to the spinal cord will be limited
to 45 Gy.
The spinal cord dose must not exceed 45 Gy maximum. Normal
lung (more than 2 cm
outside the target volume) must not receive more than 45 Gy.
The entire heart dose
should be no more than 30 Gy with < 50% of the organ
receiving a maximum of 40 Gy.
Typical radiation technique as described in the current RTOG
esophagus trial (E-0113)

8. RADIATION THERAPY ONCOLOGY GROUP. RTOG E-0013
NON-OPERATIVE
THERAPY OF LOCAL-REGIONAL CARCINOMA OF THE
ESOPHAGUS: A
RANDOMIZED PHASE II STUDY OF TWO PACLITAXEL-
BASED
CHEMORADIOTHERAPY REGIMENS
Arm 1 (5-FU-based)
Induction chemotherapy with 5-FU, cisplatin, paclitaxel (up to 2
cycles) followed by (on
day 29 of the last cycle)continuous
96-hr. infusion 5-FU and weekly paclitaxel with concurrent
radiotherapy* (50.4 Gy) [G-
CSF given from days 6-15 and 34-42]
Arm 2 (Non-5-FU-based)
Induction chemotherapy with paclitaxel and cisplatin
(up to 2 cycles) followed by (on day 29 of the last cycle)
continous
96-hr. infusion paclitaxel and weekly cisplatin with concurrent
radiotherapy* (50.4 Gy).
Routine G-CSF administration is not planned.
6.0 RADIATION THERAPY
Participating institutions must utilize 3-D CT planning and must
be able to comply with
the criteria described below.
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9. 6.1 Dose Specifications
6.1.1 The prescription dose will be specified at the ICRU-50
reference point, which is
defined in Section 6.4.1.3. Note: this point will usually be the
isocenter (intersection of
the beams). The isodose curve representing 93% of the
prescription dose must
encompass the entire planning target volume (PTV), which is
defined in Section 6.4.1.2.
6.1.2 The daily prescription dose will be 1.94 Gy at the ICRU
reference point. 1.8 Gy
(which corresponds to the 93% isodose curve) is to be delivered
to the periphery of the
PTV.
6.1.4 The total dose for both arms will be 50.4 Gy (1.8
G/Fx/day) prescribed to the
periphery (93% isodose curve) of the PTV.
6.3.1 A volumetric treatment planning CT study will be required
to define gross tumor
volumes (GTV) and planning target volume (PTV). For this
study, the local regional
nodes (whether clinically positive or negative) will be included
in the clinical target
volume (CTV) (Appendix VI) . Each patient will be positioned
in an individualized
immobilization device in the treatment position on a flat table.
Contiguous CT slices, 3-5
mm thickness of the regions, harboring gross tumor and grossly
enlarged nodes and 8-
10 mm thickness of the remaining regions, are to be obtained

10. starting from the level of
the cricoid cartilage and extending inferiorly through the liver.
The GTV and PTV and
normal organs will be outlined on all appropriate CT slices and
displayed using beam’s
eye view. Normal tissues to be contoured include both lungs,
skin, heart, spinal cord,
esophagus, and liver. A measurement scale for the CT image
shall be included.
6.3.2 For cervical primaries (defined as tumors above the
carina), the bilateral
supraclavicular nodes need to be included. The preferable
method is a 3 field technique
(2 anterior obliques and a posterior field). In most cases, this is
not possible; therefore, it
is acceptable to initially treat AP/PA to approximately 39.6 Gy
then switch to obliques to
exclude the spinal cord. The supraclavicular field, which is
excluded from the obliques,
can be supplemented with electrons to bring the total dose up to
50.4 Gy (calculated 3
cm below the skin surface). For mid-esophageal primaries (at or
below the carina), the
paresophageal nodes need to be included—not the
supraclavicular or celiac. For
distal/gastroesophageal primaries, the field should include the
celiac nodes.
6.3.3 Barium swallow during the planning CT is optional
provided a diagnostic chest CT
was done with contrast to delineate the outline of the
esophagus.
6.3.4 Optimal immobilization is critical for this protocol. Alpha
cradle or approved

11. alternative immobilization system is required; Patients may be
placed on the supine or
prone position. In general, supine is recommended for proximal
and distal primaries
whereas prone is recommended for mid-esophageal
6.4.1.1 Gross Tumor Volume (GTV) is defined as all known
gross disease as defined by
the planning CT and clinical information. Gross tumor includes
the primary tumor (GTV-
P) only. Note: ICRU Report #50 also defines a clinical target
volume (CTV) that includes
the area of subclinical involvement around the GTV. For this
protocol, we have chosen
to define the CTV a minimum of 4 cm proximal and distal and 1
cm lateral beyond the
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GTV delineated by CT scan and/or endoscopy (endoscopy is
preferable). The final CTV
may be larger since for cervical primaries, the supraclavicular
nodes need to be
included, and for distal primaries, the celiac nodes need to be
included in the treatment
fields.
6.4.1.2 Planning Target Volume (PTV) will provide margin
around the CTV to
compensate for variability in treatment setup, breathing, or
motion during treatment. A
margin around the CTV will define the PTV. The PTV volume

12. must include a minimum of
1 cm and a maximum of 2 cm around the CTV. Therefore, the
superior and inferior
margins will be approximately 5 cm beyond the GTV, and the
lateral margins will be
approximately 2 cm beyond the GTV. Once again, the final PTV
may be larger since for
cervical primaries, the supraclavicular nodes need to be
included, and for distal
primaries, the celiac nodes need to be included in the treatment
fields.
6.8.2 The gross tumor volume (GTV) includes the known
disease as determined by
physical examination, imaging studies and other diagnostic
information.
6.8.3 The clinical target volume (CTV) includes the area of
subclinical involvement
around the GTV. The CTV is the GTV plus the margin for
clinical negative or positive
local regional nodes.
6.8.4 The planning clinic volume (PTV) is the CTV plus a
margin to ensure that the
prescribed dose is actually delivered to the GTV. This margin
accounts for variations in
treatment delivery, including variations in set-up between
treatments, patient motion
during treatment, movement of the tissues that contain the GTV
(e.g., respiration), and
size variations in the tissue containing the GTV. The PTV is a
geometric concept.

13. Diagnosis and staging of esophageal cancer
INTRODUCTION — Squamous cell carcinoma and
adenocarcinoma account for more than 95
percent of esophageal malignant tumors. For most of the
twentieth century, squamous cell
carcinomas comprised the vast majority of esophageal cancers.
In the 1960s, squamous cell
cancers accounted for more than 90 percent of all esophageal
tumors in the United States,
whereas esophageal adenocarcinomas were considered so
uncommon that some authorities
questioned their existence. For the past two decades, however,
the incidence of adenocarcinoma
of the esophagus has increased dramatically in Western
countries so that the two tumors now
occur with almost equal frequency
The two forms of esophageal cancer differ in a number of
features, including the location of the
tumor and predisposing factors (show table 1). Smoking and
alcohol are major predisposing
factors for squamous cell tumors while Barrett's esophagus with
specialized intestinal metaplasia
(a complication of gastroesophageal reflux disease [GERD]) and
possibly GERD itself are the
only known major risk factors for adenocarcinoma.
Survival statistics for the symptomatic patient with esophageal
cancer are poor and very highly
correlated with staging. The diagnosis and staging of

14. esophageal cancer with emphasis upon
endoscopic techniques will be reviewed here. The
epidemiology, clinical manifestations, and the
role of largely palliative endoscopic techniques in the treatment
of esophageal cancer are
discussed separately.
DIAGNOSTIC TESTING — Although barium studies may
suggest the presence of esophageal
cancer, the diagnosis is usually established by endoscopy. Early
esophageal cancer may appear
as a superficial plaque or ulceration (show endoscopy 1).
Advanced lesions may appear as a
stricture (show endoscopy 2), an ulcerated mass (show
endoscopy 3), a circumferential mass
(show endoscopy 4), or a large ulceration.
Biopsy — The endoscopic appearance of a large mucosal mass
is frequently diagnostic of
esophageal cancer. Biopsies confirm the diagnosis in more than
90 percent of cases
Early studies found that the greater the number of biopsies
taken (up to seven), the higher the
accuracy. As an example, in a series of 202 consecutive
patients, 47 of whom had gastric or
esophageal carcinoma, the percentage of correct diagnoses of
esophageal carcinoma were as
follows
First biopsy — 93 percent
Four biopsies — 95 percent
Seven biopsies — 98 percent
The addition of brush cytology specimens to seven biopsies
increased the accuracy to 100

15. percent. Seventeen percent of lesions thought to be benign
endoscopically were subsequently
proven to be malignant.
In vivo staining — In vivo staining of the esophageal mucosa
(chromoendoscopy) can help direct
the area of biopsy and determine the extent of disease. Lugol's
iodide reacts with the glycogen
components of normal squamous mucosa to produce a greenish
brown color, while neoplastic
tissue is depleted of glycogen and remains unstained. Its role in
the diagnosis and screening
esophageal cancer has not been established, although limited
data suggest that it can be helpful
in some high-risk settings
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STAGING — The outcome of esophageal cancer is strongly
associated with its stage. As a result,
accurate clinical staging is critical for selecting an appropriate
treatment option. Staging usually
begins with a CT scan to evaluate for the presence of metastatic
disease. Patients without
evidence of metastatic disease by CT frequently undergo

16. endoscopic ultrasonography (EUS),
which uses a high frequency ultrasound transducer to provide
detailed images of esophageal
masses and their relationship with the five-layered structure of
the esophageal wall. Miniature
ultrasound probes that are placed through the accessory channel
of an endoscope with high
ultrasound frequencies (typically 20 mHz) have also been used
to accurately stage mucosal
malignancies.
EUS provides the most accurate estimate of disease stage and
assists with management
decisions. The accuracy of EUS staging has been investigated in
a large number of patients and
sites using operative specimens. EUS consistently provides
better regional TNM tumor staging
than CT scanning. Local invasion of the middle esophagus is
well documented by CT, but CT is
much less accurate for detecting lymph node metastases. One
advantage of CT is that it detects
distant solid organ metastases with an accuracy of over 90
percent.
However, EUS may be less accurate for staging patients who
have undergone preoperative
chemoradiotherapy. In one report, for example, EUS correctly
predicted a complete response to
chemoradiotherapy in only 3 of 17 patients (17 percent) who
had no residual tumor demonstrated
in resection specimens [9]. This study suggests that different
criteria will be needed to predict
regional malignancy. Measuring the change in maximal cross-
sectional area pre- and post-
chemoradiotherapy may be a more useful measure to assess the
response of esophageal cancer

17. to preoperative chemoradiation
The TNM staging system of the American Joint Committee on
Cancer (AJCC) and the
International Union Against Cancer (UICC) for esophageal
cancer is used universally. The
importance of staging is reflected in prognosis. Reported five-
year survival rates for stages I to IV
disease are 60, 31, 20, and 4 percent, respectively
T1 esophageal tumors — Early esophageal cancer is usually
diagnosed endoscopically by
recognizing small mucosal defects or nodules. T1 masses are
those tumors that are localized to
either the mucosa or lamina propria (T1a) or submucosa (T1b)
by EUS. T1 lesions are usually
seen with EUS and are staged as such by determining that the
mass does not involve the
muscularis propria.
With traditional endoscopic ultrasound using transducers with a
frequency of less than 12 mHz, it
may be difficult to identify and stage a mucosal malignancy.
High frequency ultrasound probes
can accurately stage early lesions and help determine which
ones can be treated with local
excision alone (T1a tumors).
T2, T3, and T4 esophageal tumors — T2, T3, and T4 tumors are
readily seen on endoscopy, and
appear as either a stricture, ulceration, or an exophytic mass
T2 masses are defined as those that involve the muscularis
propria, but without transmural
invasion (ie, they are intraesophageal). They appear as an
irregular hypoechoic mass

18. involving the esophageal wall on EUS, leaving the muscularis
intact as evidenced by a
smooth contour of the mass and muscularis propria.
T3 and T4 tumors are extraesophageal. Masses that extend into
the adventitia are stage T3.
T4 masses have invaded through the muscularis propria and
adventitia and involve a
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mediastinal structure such as the pericardium, aorta, bronchus,
or pleura. EUS identifies T4
lesions by demonstrating tumor invasion into mediastinal
structures, most often pulmonary
vessels.
The presence of an irregular outer border suggests that a mass
has invaded through the wall of
the esophagus. In addition, measurement of maximal thickness
of the esophageal mass can also
predict extraesophageal extension. In one report, for example,
T3-T4 masses had a significantly
greater thickness than T1-T2 masses (16 versus 8.2 mm). The
thickness of the tumor was a more

19. accurate predictor of staging (which was determined by
esophageal resection) than muscularis
disruption.
A caveat for EUS staging of esophageal lymph nodes is that the
instrument cannot traverse a
tumor-induced stenosis (which occurs in about 30 percent of
cases). In these settings, EUS may
understage the tumor, since the entire lesion and the celiac axis
are not seen. It is controversial
as to whether to dilate the esophagus for the purpose of a
staging examination, since perforations
have occurred. An alternative is to use miniature EUS probes,
which are passed through the
biopsy channel of an endoscope. However, these devices only
provide a partial solution to the
problem because of the limited depth of penetration
(approximately 3 cm). A nonoptical, wire-
guided echoendoscope is another alternative that allows for
complete EUS staging in the majority
of patients
Regional lymph nodes — EUS can provide nodal staging of
esophageal cancer by either imaging
nodes in detail or guiding needle biopsies. Malignant lymph
nodes appear as large (>1 cm),
rounded, hypoechoic structures with a discrete border often
directly adjacent to an esophageal
mass.
EUS has an accuracy of more than 80 percent for detecting
metastatic nodes in the cervical
paraesophageal, right recurrent laryngeal, left paratracheal,
upper and lower paraesophageal,
infraaortic, infracarinal, and lower posterior mediastinal regions
Its sensitivity is highest for cervical

20. and upper thoracic paraesophageal, infracarinal, left
paratracheal, and recurrent laryngeal nodes.
Accuracy is maximum for periesophageal nodes and varies
inversely with the axial distance of the
nodes from the esophageal axis. The accuracy is further
increased when nodes are aspirated, but
this can only be performed in nodes that are accessible and in
which the primary tumor is not in
the pathway of the aspiration needle.
The most important nodal group to be examined is the celiac
area. The finding of a malignant
node in the retrogastric area remote from the primary tumor is a
sign of unresectability or distant
metastatic disease.
Several approaches are being evaluated in an attempt to improve
the accuracy of regional lymph
node staging for esophageal cancer. Thoracoscopic and
laparoscopic staging accurately assess
thoracic and celiac node status. In one multiinstitutional study
conducted by the Cancer and
Leukemia Group B, for example, noninvasive testing methods
(CT, MRI, EUS) were found to each
incorrectly identify disease status (either falsely negative lymph
nodes or the presence of
metastatic disease) in 50, 40, and 30 percent of patients,
respectively, as assessed by
thoracoscopic or laparoscopic staging
Similar results were noted in another report of 26 patients, in
which laparoscopy and
thoracoscopy appeared to be more accurate than EUS. EUS
suggested NO disease in eight
patients, while laparoscopy and thoracoscopy documented N1
disease in six of the eight.

21. Laparoscopy and thoracoscopy also had the advantage of
allowing evaluation of the thoracic and
abdominal cavities for metastases.
Immunohistochemical examination of lymph nodes is another
method that may significantly
improve pathologic staging. In a study of 1308 lymph nodes
from 68 patients with esophageal
cancer without overt metastases who underwent radical en bloc
esophagectomy, 399 were found
to be free of tumor by routine histopathology. These nodes were
further studied by
immunohistochemistry with the monoclonal antiepithelial-cell
antibody Ber-EP4; 67 (17 percent)
stained positively. Fifteen of 30 patients considered free of
lymph node metastases had such cells
in their lymph nodes. The finding of positive staining in nodes
thought to be metastasis-free had
predictive prognostic significance; positive cells predicted
relapse in both patients without nodal
metastases and in those with regional lymph node involvement.
All 12 patients whose lymph
nodes were negative on both histopathologic and
immunohistochemical analysis survived without
recurrence.
Distant metastases — M staging has been primarily performed
using CT scanning. While
relatively inexpensive, CT is limited in its ability to identify
locally advanced or subclinical
metastatic disease, particularly in the peritoneal cavity. EUS is
being increasingly used for this
purpose since it can diagnose liver metastases <1 cm or

22. malignant ascites; needle aspiration can
provide a tissue diagnosis for either of these findings.
Other staging modalities, laparoscopy and PET scanning, have
been used to improve the
detection of patients with occult metastases, in an attempt to
limit aggressive treatment to those
who are most likely to benefit from it. In at least one study of
26 patients with gastric or
esophageal cancer, M staging accuracies for laparoscopic US
versus laparoscopy versus CT
were 89, 44, and 64 percent respectively . However,
laparoscopy is invasive, and requires
hospitalization and general anesthesia.
PET scans — Positron emission tomography (PET) with 18F-
fluorodeoxyglucose is a noninvasive
staging modality that is more sensitive than CT for the detection
of distant metastases]. In two
studies totaling 94 patients, PET prevented needless surgery in
22 who had metastatic disease
undetected by CT aloneIn a study of 91 patients with esophageal
cancer, PET scans detected 51
metastases in 27 of 39 cases (69 percent sensitivity, 93.4
percent specificity, 84 percent accuracy)
and was more accurate than CT at detecting distant metastases
In contrast to improved detection of metastatic disease, PET
scans are not as useful in the
evaluation of the primary site and locoregional nodes. One
study prospectively compared PET
scanning to preoperative CT and EUS in 74 patients with
potentially operable cancer of the
esophagus or GE junction. At the primary site, PET scanning
showed increased activity in 70 of
74 patients, but was falsely negative in four patients with T1

23. tumors. Thirty of the 74 patients
underwent lymphadenectomy at the time of esophageal
resection. PET scanning was not as
sensitive as EUS for the detection of local lymph nodes
(sensitivity 33 versus 81 percent) and had
only slightly better specificity (89 versus 67 percent).
Nevertheless, the improved sensitivity of PET for the detection
of metastatic disease makes it
potentially the most cost-effective method of identifying
patients with occult metastases, for whom
aggressive therapy should not be pursued. This hypothesis was
directly tested in a decision
analysis model that compared several different staging
strategies, and was conducted in parallel
with a prospective clinical trial. When compared with the
staging strategy of CT plus EUS/FNA,
PET plus EUS/FNA was slightly more expensive (by $4158 on
average), and only associated with
a one-month benefit in quality adjusted life years. The marginal
cost-effectiveness ratio of this
strategy ($60,544 per QALY) did not compare favorably with
other accepted medical treatments.
The use of PET scanning for initial staging of esophageal
cancer is covered by Medicare.
Preoperative bronchoscopy with biopsy and brush cytology has
been advocated by some as the
last investigation in the staging workup, and is reasonable in
patients with advanced tumors of the
proximal esophagus. In one study of 116 consecutive patients
with potentially operable
esophageal carcinoma, bronchoscopy was superior to CT and

24. was the sole decisive procedure
resulting in exclusion from surgery because of airway invasion
in 10 percent of patients
SUMMARY AND RECOMMENDATIONS — The diagnosis of
esophageal cancer is usually
established by endoscopy Early esophageal cancer may appear
as a superficial plaque or
ulceration). Advanced lesions may appear as a stricture , an
ulcerated mass a circumferential
mass , or a large ulceration. The endoscopic appearance of a
large mucosal mass is frequently
diagnostic of esophageal cancer. Biopsies confirm the diagnosis
in more than 90 percent of cases
Staging usually begins with a CT scan to evaluate for the
presence of metastatic disease.
Patients without evidence of metastatic disease by CT
frequently undergo endoscopic
ultrasonography (EUS), which uses a high frequency ultrasound
transducer to provide detailed
images of esophageal masses and their relationship with the
five-layered structure of the
esophageal wall.
Esophageal Cancer
While still relatively uncommon in western countries,
esophageal cancer is fatal in the vast majority
of cases. An estimated 12,500 new cases will be diagnosed in
the year 2000, and 12,200 deaths
will result from the disease. This high percentage of deaths
rivals that of pancreatic cancer and is

25. more than four times that of rectal cancer.
The esophagus extends from the cricopharyngeal sphincter to
the gastroesophageal (GE) junction
and is commonly divided into the cervical, upper to mid-
thoracic, and thoracic portions. This can be
important, as histology and optimal treatment approaches may
vary considerably based on the site
of the cancer. It may not be possible to determine the site of
origin if the cancer involves the GE
junction itself.
Epidemiology
Gender Esophageal cancer is 2.7 times more common and
slightly more lethal in men than in
women.
Age The incidence of squamous cell cancer of the esophagus
increases with age and peaks in the
seventh decade of life. However, adenocarcinoma of the
esophagus is now more common in the
United States than the squamous cell type, with the greatest
frequency in white males 40-50 years
old.
Race The incidence of squamous cell esophageal cancer is three
times higher in blacks than in
whites, while adenocarcinomas are increasingly more common
in whites.
Geography Evidence for an association between environment
and diet and esophageal cancer
comes from the profound differences in incidence observed in
different parts of the world.
Esophageal cancer occurs at a rate 20-30 times higher in China

26. than in the United States. An
esophageal “cancer belt” extends from northeast China to the
Middle East.
Survival While the overall outlook for patients diagnosed with
esophageal cancer has improved in
the last 30 years, most patients still present with advanced
disease and their survival remains poor.
Between 1983 and 1990, only 25% of patients with esophageal
cancer presented with localized
disease.
Disease site The rate of cancer of the distal esophagus is about
equal to that of the more proximal
two-thirds. In general, squamous cell carcinoma is found in the
body of the esophagus, whereas
adenocarcinoma predominates in lesions closer to the GE
junction.
Etiology and risk factors
Cigarettes and alcohol Most cases of squamous cell carcinoma
of the esophagus can be attributed
to cigarette smoking or excessive alcohol intake. Furthermore,
these two habits can act
synergistically and produce very high relative risks in heavy
tobacco and alcohol users.
Patients with squamous cell carcinoma of the esophagus have an
increased incidence of second
primary tumors of the head and neck and/or lung. These second
primaries may be detected prior
to, after, or at the time of diagnosis of the esophageal
carcinoma. The association of these tumors
may reflect a cancer “field” defect associated with smoking and
alcohol use.

27. J. Arredondo
http://www.aboutcancer.com/esophagus_review.htm
A population-based, case-control study from Sweden showed a
strong,
probably causal relationship between gastroesophageal reflux
and
esophageal adenocarcinoma (Lagergron J, Bergstrom R, Lindren
A, et al: N
Engl J Med 340:825-831, 1999).
Diet High-fat, low-protein, and low-calorie diets have also been
shown to increase the risk of
esophageal cancer. A common etiology may be exposure to
nitrosamines, which has been
proposed as a factor in the development of both squamous cell
carcinoma and adenocarcinoma of
the esophagus.
Barrett’s esophagus and other factors Barrett’s esophagus
(adenomatous metaplasia of the distal
esophagus), tylosis, Plummer-Vinson syndrome, and achalasia
have also been associated with a
higher-than-normal risk of developing esophageal cancer.
Signs and symptoms
Few esophageal cancers are diagnosed at an early stage,
suggesting that symptoms do not alert
the patient until the disease is advanced. This, along with the
high incidence rate, is the justification

28. for the screening procedures considered routine in parts of the
world, such as China.
Dysphagia The most common presenting complaint is
dysphagia, which generally is not noted until
the esophageal lumen is narrowed to one-half to one-third of
normal, due to its elasticity.
Weight loss is common and often significant (> 10% of total
body weight).
Cough that is induced by swallowing is suggestive of local
extension into the trachea with resultant
tracheo-esophageal fistula.
Pain Patients who describe pain radiating to the back may well
have extraesophageal spread.
Supraclavicular or cervical nodal metastases may be appreciated
on examination.
Hoarseness may be a sign of recurrent laryngeal nerve
involvement due to extraesophageal
spread.
Metastatic disease may present as malignant pleural effusion or
ascites. Bone metastasis can be
identified by pain involving the affected site or by associated
hypercalcemia.
Screening and diagnosis
Routine screening for esophageal cancer is not generally
practiced in western countries because
the disease is relatively uncommon. Mass screening is
appropriate in high-risk areas, such as
China and Japan.

29. High-risk patients Individuals at increased risk for esophageal
cancer, in whom close screening
endoscopy or barium swallow is justified, include patients with
Barrett’s esophagus and patients
diagnosed with squamous cell carcinoma at another site in the
upper aerodigestive tract. Screening
examinations also should be considered in immigrants from
high-risk regions.
Endoscopic ultrasound (EUS) is a relatively new staging
technique that complements information
gained by CT. Specifically, depth of tumor invasion can be
assessed more accurately by EUS than
by CT. EUS also can detect local tumor recurrence at an early
stage.
Endoscopy and barium x-rays The diagnosis of esophageal
cancer in a patient presenting with any
constellation of the symptoms described above revolves around
the use of upper endoscopy or
double-contrast barium x-rays. The advantage of endoscopy is
that it allows for direct visualization
of abnormalities and directed biopsies. Barium x-rays do not
facilitate biopsies but are less invasive
and also can identify small abnormalities.
Bronchoscopy should be performed to detect tracheal invasion
in all cases of esophageal cancer
except adenocarcinoma of the distal third of the esophagus.
CT scan Once a diagnosis has been established and careful
physical examination and routine

30. blood tests have been performed, a CT scan of the chest,
abdomen, and pelvis should be obtained
to help assess tumor extent, nodal involvement, and metastatic
disease.
PET Numerous studies report the accuracy of PET scanning in
determining the presence of
metastatic disease, with sensitivity approaching 90% and
specificity over 90%. As PET becomes
more widely available, its use will probably become an
important part of the preoperative evaluation
of these patients.
Bone scan A bone scan should be obtained if the patient has
bone pain or an elevated alkaline
phosphatase level.
Pathology
Adenocarcinoma The incidence of esophageal adenocarcinoma
involving the GE junction has risen
4%-10% per year since 1976 in the United States and Europe.
As a result, adenocarcinoma is now
the predominant histologic subtype of esophageal cancer. The
distal one-third of the esophagus is
the site of origin of most adenocarcinomas.
Squamous cell carcinomas, previously the most common
histologic subtype in the United States,
occur most often in the proximal two-thirds of the esophagus.
Squamous cell carcinoma is still the
most prevalent histologic subtype worldwide.
Other tumor types Other, less frequently seen histologic
subtypes include mucoepidermoid
carcinoma, small-cell carcinoma, sarcoma, adenoid cystic

31. carcinoma, and primary lymphoma of the
esophagus. Occasionally, metastatic disease from another site
may present as a mass in the
esophagus.
Metastatic spread The most common sites of metastatic disease
are the regional lymph nodes,
lungs, liver, bone, adrenal glands, and diaphragm.
Adenocarcinoma can also metastasize to the
brain.
Staging and prognosis
Based on data demonstrating that the depth of penetration has
important prognostic significance,
the American Joint Committee on Cancer (AJCC) TNM staging
system for esophageal cancer was
changed from a clinical one (1983) to a pathologic one in 1997.
Both the clinical and pathologic
staging systems are shown in Table 1, as the curative approach
may or may not be primarily an
operative one.
http://www.cancernetwork.com/handbook/images/esophageal%2
0t1.gif
The initial endoscopic biopsy specimens of 112 patients treated
with
fluorouracil (5-FU), cisplatin (Platinol), and concurrent
radiation followed by
esophagogastrectomy were subjected to immunohisto-chemical
analysis.
Markers studied included p53, HER-2/neu, and P-glycoprotein.
The analysis
suggested improved overall survival in patients whose tumors

32. were HER-
2/neu-positive (26.8 vs 14.5 months) and P-glycoprotein-
negative (20.9 vs >
60 months) (Harpole DH, Moore M-B, Aloia TA, et al: Proc Am
Soc Clin
Oncol 18:387a [abstract], 1999).
Pathologic information obtained from an esophagectomy
specimen is of significant prognostic
importance. Immunohisto-chemical analysis of the initial biopsy
specimen may also have
prognostic relevance (see box). Clinical staging has also been
shown to be of prognostic
importance, particularly in patients managed with primary
radiotherapy or chemoradiation.
EUS, mediastinoscopy, and laparoscopy are being used to
clinically stage patients prior to
treatment. CT is accurate in determining liver and abdominal
node metastasis in 98% and 78% of
cases, respectively. EUS correlates with final pathologic T- and
N-stages in 85% and 75% of cases,
respectively.
Histology and grade Neither histology nor grade has been
shown to be of prognostic importance in
esophageal carcinoma.
Other prognostic factors Patient age, performance status, and
degree of weight loss are of
prognostic importance. The prognostic implications of tumor-
suppressor genes and oncogenes are
an area of active investigation.
Treatment

33. Treatment options for the various disease stages are given in
Table 2, along with 5-year survival
rates.
Treatment of localized disease
Only 40%-60% of patients with esophageal cancer present with
clinically localized disease. This
group of patients have been treated predominantly with surgical
resection as primary therapy. Even
in these patients, however, resection often is not curative. The
overall 5-year survival rate after
surgery is between 5% and 20%, except in the rare patients with
pathologic stage I disease, in
whom 5-year survival can exceed 50%.
Chemoradiation as primary management of localized or
locoregionally confined esophageal cancer
has been shown to be superior to radiation alone. No
randomized trial of chemoradiation vs
esophagectomy as primary therapy has ever been completed;
thus, both have been used as initial
management of localized esophageal cancer.
Surgery
Preoperative evaluation helps determine the patient’s risk of
developing postoperative
complications and mortality. In a study of 800 patients, a risk
score was developed based on
general status; pulmonary, hepatic, renal, and cardiac function;
and tumor staging. Using those risk
scores, the investigators were able to reduce 90-day mortality
from 16% to 6% in the last 250
patients.

34. http://www.cancernetwork.com/handbook/images/esophageal%2
0t2.gif
Patient selection The indications for esophagectomy in
esophageal cancer are very controversial.
The use of EUS has improved the staging of esophageal lesions,
with better determination of the
depth of tumor invasion.
Clearly, patients with distant metastases, evidence of nodal
metastases in more than one nodal
basin, or tumor extension outside of the esophagus (airway,
mediastinum, vocal cord paralysis) are
candidates for palliative surgery only, or are probably better
treated with combined chemotherapy
and radiation. Patients with disease limited to the esophagus
and no evidence of nodal metastases
(stages I and IIa) may be treated with esophagectomy, although
these patients can also be
considered for chemoradiation. Patients with disease limited to
the esophagus and N1 disease
(stage IIb) do not do well with esophagectomy alone.
Esophagectomy following chemoradiation Considerable
controversy exists regarding the need for
esophagectomy following chemoradiation. To date, no study has
compared patients treated with
chemoradiation alone vs those treated with chemoradiation
followed by surgery. The incidence of
residual disease in patients who have a complete response to
chemoradiation is 40%-50%; half of
these patients are long-term survivors, supporting the use of
esophagectomy. CT and EUS findings
correlate poorly with pathologic stage and response following
chemoradiation (see

35. “Chemoradiation” below).
Extent of resection The extent of the resection depends on the
location of the primary tumor,
histology of the tumor, and nature of the procedure (palliative
vs curative). For tumors of the
intrathoracic esophagus (squamous cell carcinomas) and tumors
with extensive Barrett’s
esophagus (adenocarcinomas), it is necessary to perform a total
esophagectomy with cervical
anastomosis in order to achieve reasonable disease-free
margins. For distal lesions of the
abdominal esophagus (adenocarcinomas) and cardia, it is often
possible to perform an
intrathoracic esophageal anastomosis above the azygous vein,
although many surgeons would
prefer to perform a total esophagectomy.
A total of 199 patients (94% of whom had squamous cell
carcinomas)
underwent radical esophagectomy with three-field (cervical,
mediastinal, and
abdominal) lymphadenectomy. Tumors invaded at least to the
submucosa,
and patients had no evidence of nodal metastases. Mortality was
1.6%; 45%
of patients developed vocal cord paralysis. Overall survival at 5
years was
78% for N0, 49% for N+ (1-4 nodes), and 6% for N+ (> 4
nodes) disease.
There were no long-term survivors among patients with
metastases in the
three fields, metastases to > 5 nodes, or distal-third tumors with
cervical
lymph node metastases (Nishimaki T, Suzuki T, Kuwabara S, et
al: Am Coll

36. Surg 186(3):306-312, 1998).
The resected esophagus may be replaced with tubularized
stomach in patients with tumors of the
intrathoracic esophagus or with a colon interposition in patients
with tumors involving the proximal
stomach, since such involvement makes this organ unsuitable
for esophageal reconstruction. The
esophageal replacement is usually brought up through the
posterior mediastinum, although the
retrosternal route is often used in palliative procedures.
Method of resection Considerable controversy exists among
surgeons regarding the method of
resection. To date, two randomized studies have compared
transhiatal esophagectomy (without
thoracotomy) with the Ivor-Lewis (transthoracic)
esophagectomy (with thoracotomy). These studies
failed to show differences between the two procedures with
regard to operative morbidity and
mortality. The studies were too small to detect a difference in
survival.
Lymphadenectomy Considerable controversy exists regarding
the need for radical
lymphadenectomy in esophageal disease. Much of the
controversy is due to the fact that different
diseases are being compared.
Japanese series include mostly patients with squamous cell
carcinomas of the intrathoracic
esophagus, with 80% of the tumors located in the proximal and
middle sections of the esophagus.

37. Americans report combined series, with at least 40%-50% of
patients with distal esophagus
adenocarcinomas. Skinner and DeMeester favor en bloc
esophagectomy with radical (mediastinal
and abdominal) lymphadenectomy, based on 5-year survival
rates of 40%-50% in patients with
stage II disease, as compared with rates of 14%-22% in
historical controls.
In a retrospective study, Akiyama found a 28% incidence of
cervical node metastases in patients
with squamous cell carcinomas located in the middle and distal
portions of the esophagus, as
opposed to 46% in those with tumors of the proximal third.
Overall survival at 5 years was
significantly better in patients who underwent extended
lymphadenectomy (three fields) than in
those who had conventional lymphadenectomy (two fields); this
was true in patients with negative
nodes (84% and 55%, respectively) and in those with positive
nodes (43% and 28%, respectively).
Extended lymphadenectomy afforded no survival advantage in
patients with tumors in the distal
third of the esophagus.
A total of 199 patients (94% of whom had squamous cell
carcinomas)
underwent radical esophagectomy with three-field (cervical,
mediastinal, and
abdominal) lymphadenectomy. Tumors invaded at least to the
submucosa,
and patients had no evidence of nodal metastases. Mortality was
1.6%; 45%
of patients developed vocal cord paralysis. Overall survival at 5
years was
78% for N0, 49% for N+ (1-4 nodes), and 6% for N+ (> 4

38. nodes) disease.
There were no long-term survivors among patients with
metastases in the
three fields, metastases to > 5 nodes, or distal-third tumors with
cervical
lymph node metastases (Nishimaki T, Suzuki T, Kuwabara S, et
al: Am Coll
Surg 186(3):306-312, 1998).
In summary, radical lymphadenectomy may confer a survival
advantage in patients with
esophageal cancer. Cervical lymphadenectomy should be
reserved for patients with squamous cell
carcinoma of the proximal two-thirds of the esophagus.
Chemoradiation
Preoperative chemoradiation Initial trials of preoperative
chemoradiation reported unacceptably
high operative mortality (~ 26%). Subsequent trials reported
4%-11% operative mortality, median
survival as long as 29 months, and 5-year survival rates as high
as 34%. In general, 25%-30% of
patients have no residual tumor in the resected specimen, and
this group tends to have a higher
survival rate than those who have a residual tumor discovered
by the pathologist.
The superiority of preoperative chemoradiation over surgery
alone in esophageal adenocarcinoma
has been demonstrated in a prospective trial. This trial included
113 patients with adenocarcinoma
of the esophagus. These patients were randomized either to
preoperative chemoradiation (2
courses of 5-FU and cisplatin given concurrently with 40 Gy of
radiotherapy in 15 fractions) or to

39. surgery alone. Median survival was statistically superior in the
combined-modality arm than in the
surgery-alone arm (16 vs 11 months). Rates of 3-year survival
again statistically favored the
combined-modality arm (32% vs 6%). Toxicity was not severe.
A similar study in esophageal squamous cell carcinoma showed
improved disease-free survival
and a higher frequency of curative resection among patients
treated with preoperative
chemoradiation, but this did not alter overall survival, which
was 18.6 months for both groups. This
study used low total doses of split-course radiation.
Primary chemoradiation In light of the significant rate of
complete pathologic response to
moderately aggressive chemoradiation regimens administered
preoperatively, the role of this
treatment in a more intense form as primary management
remains an area of active investigation.
In a nonrandomized, single-institution trial, patients with stage
I or II cancers were treated with 60
Gy concurrent with 5-FU and mitomycin (Mutamycin). Median
disease-specific survival duration
was 20 months, with a 5-year actuarial disease-specific survival
rate of 29%. Most patients had
excellent preservation of swallowing function after treatment.
Surgical resection as salvage was
successful in patients with local failure only.
Randomized trials have demonstrated a survival advantage for
chemoradiation over radiotherapy

40. alone in the treatment of esophageal cancer. In a Radiation
Therapy Oncology Group (RTOG)
randomized trial involving 129 esophageal cancer patients,
radiation (50 Gy) with concurrent
cisplatin and 5-FU provided a significant survival advantage
(27% vs 0% at 5 years) and improved
local control over radiation therapy alone (64 Gy). Median
survival also was significantly better in
the combined-therapy arm than in the radiation arm (14.1 vs 9.3
months).
Numerous recently published phase I and II studies have
demonstrated excellent response rates to
chemoradiation regimens utilizing taxanes. Future trials will
continue to explore these
combinations.
Patient selection Patients with disease involving the mid- to
proximal esophagus are excellent
candidates for definitive chemoradiation. This is because
resection in this area can be associated
with greater morbidity than resection of more distal tumors.
Most of the trials demonstrating the efficacy of chemoradiation
have had a high proportion of
patients with squamous cell cancers. Chemoradiation has thus
become a standard treatment for
locoregionally confined squamous cell cancer of the esophagus.
It is essential that chemotherapy
be given concurrently with radiation when this approach is
chosen as primary treatment for
esophageal cancer. A typical regimen is 50-60 Gy over 5-6
weeks with cisplatin (75 mg/m²) and 5-
FU (1 g/m²/24 h for 4 days) on weeks 1, 5, 8, and 11.
The literature also supports offering patients with

41. adenocarcinoma primary surgery, preoperative
chemoradiation, or primary chemoradiation with surgical
salvage if necessary. Entering these
patients on protocols will allow us to further define standard
treatment.
Radiotherapy
Radiotherapy alone is inferior to chemoradiation in the
management of locoregionally confined
esophageal cancer.
Preoperative radiotherapy has been shown to be of little value
in converting unresectable cancers
into resectable ones or in improving survival. However, it
decreases the incidence of locoregional
recurrence.
Postoperative radiotherapy (usually to 50 or 60 Gy) can
decrease locoregional failure following
curative resection but has no effect on survival.
Brachytherapy Intraluminal isotope radiotherapy (intracavitary
brachytherapy) allows high doses of
radiation to be delivered to a small volume of tissue.
Retrospective studies suggest that a
brachytherapy boost may result in improved rates of local
control and survival over external-beam
radiotherapy alone. This technique can be associated with a
high rate of morbidity if not used
carefully.
Preoperative chemotherapy

42. Of three small randomized trials comparing surgery alone with
chemotherapy followed by surgery
for esophageal cancer, only one study showed a significant
improvement in survival rate in the
chemotherapy arm among the subgroup of patients who
responded. An intergroup randomized
study of preoperative chemotherapy vs surgery alone involving
over 440 patients showed no
difference in median survival or 2-year survival between the
two groups (see box). At present,
therefore, preoperative chemotherapy should not be
recommended outside of the context of a
clinical trial.
In an intergroup study, patients were randomized either to 3
cycles of 5-FU
and cisplatin followed by esophagectomy or to esophagectomy
alone.
Median survival was 14.9 months in patients given preoperative
chemotherapy vs 16.1 months in those treated with surgery
alone, while the
2-year survival rates were 35% and 37%, respectively. There
were no
differences in survival between patients with squamous cell
carcinoma or
adenocarcinoma. Chemotherapy did not decrease the rate of
locoregional or
distant failure (Kelsen DP, Ginsberg R, Pajak TK, et al: N Engl
J Med
339:1979-1984, 1998).
Treatment of advanced disease
As mentioned previously, the majority of patients with
esophageal cancer present with locally
advanced (extraesophageal spread) or metastatic disease. The

43. goal of treatment in this group is
generally palliative, as reports of long-term cure are rare.
Therapeutic approaches should temper
treatment-related morbidity with the overall dismal outlook.
Local treatment In patients with a good performance status, the
combination of 5-FU, mitomycin,
and radiotherapy (50 Gy) results in a median survival of 7-9
months. This regimen renders most
patients free of dysphagia until death and produces few severe
treatment-related complications.
Photodynamic therapy (PDT) Porfimer sodium (Photofrin) and
an argon-pumped dye laser can
provide effective palliation of dysphagia in patients with
esophageal cancer. A prospective,
randomized multicenter trial comparing PDT with
neodymium/yttrium-aluminum-garnet (Nd:YAG)
laser therapy in 236 patients with advanced esophageal cancer
found that improvement of
dysphagia was equivalent with the two treatments.
Other approaches include external-beam radiotherapy with or
without intracavitary brachytherapy
boost, simple dilatation, placement of stents, and laser
recannulization of the esophageal lumen.
Chemotherapy Single-agent chemotherapy is rarely used.
Agents with reported activity in
esophageal carcinoma include bleomycin (Blenoxane), cisplatin,
5-FU, methotrexate, mitoguazone
(methyl-GAG), mitomycin, paclitaxel (Taxol), vindesine
(Eldisine), and irinotecan (CPT-11

44. [Camptosar]). Paclitaxel as a single agent has been reported to
produce a 34% response rate in
patients with esophageal adenocarcinoma and a 28% response
rate in those with squamous cell
carcinoma.
The most commonly used combination regimen for esophageal
carcinoma has been 5-FU (usually
administered at 750-1,000 mg/m²/d as a continuous IV infusion
for 4-5 days) combined with
cisplatin (75-100 mg/m²). A recent study combined paclitaxel
with cisplatin and 5-FU. A total of 46
patients were treated, with an overall response rate of 44%.
Patients with advanced disease should be encouraged to
participate in well-designed trials
exploring novel agents and chemotherapy combinations.
Palliative resection for esophageal cancer is rarely warranted,
although in some patients it does
provide relief from dysphagia.
NSCLC T1N0M0 Left Lower Lobe 1
Lung cancer is the leading cause of cancer related deaths
in both male and females. Approximately 10% of patients with
lunch cancer will survive five years after diagnosis (Portal
Design in Radiation Therapy). According to the American
Cancer Society, approximately 170,000 new cases are diagnosed
and approximately 157,000 deaths are caused by the disease
each year (Greenlee RT, Hill-Harmon MB, 2001). Age and
gender have the most dominant effect on the epidemiology of
this disease. Men have a higher incidence than women,

45. although the mortality rates have significantly increased for
women over the past half century. The average age for onset is
60 years old.
The most common cause of lung cancer is significant
tobacco exposure. Smoking contributes to 80%-90% of lung
cancer deaths in women and men, respectively. Men who smoke
are 23 times more likely to develop lung cancer and women are
13 times more likely, compared to never smokers (U.S.
Department of Health and Human Services, 2004). Between
2005 and 2010, an average of 130,659 Americans (74,300 men
and 56,359 women) died of smoking-attributable lung cancer
each year. Exposure to secondhand smoke causes
approximately 7,330 lung cancer deaths among nonsmokers
every year (U.S. Department of Health and Human Services,
2014).
Exposure to radon is estimated to be the second leading cause of
lung cancer, accounting for an estimated 21,000 lung cancer
deaths each year. Radon is a tasteless, colorless and odorless
gas that is produced by decaying uranium and occurs naturally
in soil and rock. The majority of these deaths occur among
smokers since there is a greater risk for lung cancer when
smokers are also exposed to radon (U.S. Environmental
Protection Agency, 2013). Aside from excessive tobacco usage
and exposure to radon, additional causative factors include
exposure to combustion by-products, asbestos, pollution,
pitchblende, chemicals, metals and ionizing radiation.
Smoking cessation as well as preventing nonsmokers from being
exposed to tobacco smoke is the most efficient way to prevent
stage 1A NSCLC (American Cancer Society, 2014). LDCT,
low-dose computed tomography, is currently the only
recommended screening test for lung cancers and successfully
shows high sensitivity and acceptable specificity for the
detection of lung cancer in high-risk people. Chest radiographs
as well as cytologic evaluation can present suspicion for lung
cancer; however, they cannot be used as definitive screening
modalities because they have not shown adequate sensitivity or

46. specificity as screening tests. According to the Principles and
Practices of Radiation Therapy, the CT to the chest evaluates
the primary finding itself, the possibility of other pulmonary
lesions, the involvement of mediastinal and paramediastinal
structures and pleural or extrapleural thoracic involvement.
The left lobe of the lung is divided into two sections: the
upper lobe and the lower lobe. The right and left lobes of the
lung are separated in the midline by the mediastinum which is
composed of the heart, thymus, trachea, great vessels,
esophagus and lymph nodes. The hilum of the lung is the area
in which the blood, lymphatic vessels and nerves enter and exit
each lung.
The lymphatic system is important in lung cancer because
it is one of the principle routes of regional spread. There are
two ways cancer cells can detach from the tumor mass and enter
the lymphatics. Detached tumor cells can either undergo
regional extension, which is where the cells get trapped in the
nodes as the lymphatic fluid is filtered, then the cells continue
to colonize in the nodes and eventually pass from one node to
the next, or detached tumor cells may grow through the lymph
node and gain access to the circulatory system through the
blood vessels supplying the node.
Tolerance Doses for Dose Limiting Structures
Organ
Injury
TD 5/5 (cGy)
Heart
Pericarditis
Condition in which the sac-like covering around the heart
(pericardium) becomes inflamed.
4000
Lungs
Pneumonitis
Inflammation of the lung tissue
1750

47. Esophagus
Clinical Stricture/ Perforation
Piercing
5500
Spinal Cord
Myelitis/Necrosis
Myelitis involves the infection or the inflammation of the white
matter or gray matter of the spinal cord
4500
According to our text, involvement of the lymphatics tends to
occur early and follows the divisions of the bronchial tree. The
intrapulmonary nodes along the segmental bronchi are initially
involved, followed by spread to the hilar nodes. The lymphatic
channels then drain to the mediastinal nodes (paratracheal,
subcarinal, interalobal, paraesophageal, and upper aortic) and
ultimately to the supraclavicular nodes and are considered
regional drainage. In some cases, regional spread may be to the
adjacent lobe which would be considered metastatic spread. In
lung cancer, blood metastases are common to the liver, brain,
bone and bone marrow and small cell cancer has a high risk for
brain metastasis early on. In stage 1A NSCLC, however, there
is no regional lymph node involvement and no metastasis of the
disease.
The natural history, or the progression of stage IA NSCLC over
time in the absence of treatment, was examined in the largest
study of untreated stage I NSCLC reported to date. In this
study, a total of 19,702 patients had stage I NSCLC, of whom,
1,432 did not have surgery, chemotherapy or radiation
treatments. Of these patients, only 42 were alive 5 years after
their initial diagnosis. Results from the study indicated that
five-year overall survival for untreated stage I NSCLC was 6%
overall, among these untreated patients, the median survival
was 9 months overall. Conclusive evidence from the study
suggests that long term survival with untreated stage I NSCLC
is uncommon and the vast majority of patients die of lung

48. cancer, therefore, surgical resection or other treatments should
not be delayed for patients diagnosed with stage I NSCLC. (Dr.
Raz, Zell, Ou, Gandara, Jablons, 2007).
Signs and symptoms at the clinical presentation of lung
cancer often include a history of smoking, a persistent and
unproductive cough, hoarseness, hemoptysis, weight loss,
dyspnea, unresolved pneumonitis, chest wall pain, atelectasis,
pleural effusion and weakness in arm or swelling in neck for
apical lung tumors. Lung cancer, however, often produces no
symptoms until the disease is well advanced. For stage IA
NSCLC, according to the Principles and Practices of Radiation
Therapy, approximately 75% of patients experience a cough
with 60% of patients experiencing hemoptysis, blood associated
with the cough upon clinical presentation. Approximately 15%
of patients complain of a recent onset of dyspnea and a similar
percentage exhibit chest pain.
The workup for the detection and diagnosis of lung cancer
initially consists of obtaining the patients history and a physical
examination of the patient with a chest x-ray. CT chest
exanimations of the thorax and abdomen using PA and lateral
projections are used for the detection of lung cancer. The
process of diagnosis includes acquisition of anatomical imaging
and a biopsy. CT examinations are often crucial in selecting
sites for a biopsy. MRI and PET imaging modalities are also
used in the detection and diagnosis of NSCLC. MRI reveals
invasion evidence of a tumor into the chest wall, diaphragm, or
other areas and the PET CT which provides a clearer picture of
what type of cells might be growing via visualization of
metabolic activity.
Tumor markers such as ALK gene rearrangements and
EGFR mutation analysis are examined via analyzing the tumor
tissue from biopsy to help determine treatment and prognosis of
NSCLC. Alpha-fetoprotein (AFP) is another tumor marker
utilized by analyzing blood which aids in monitoring to
recurrence. Pulmonary function laboratory tests and studies
measure how well the lungs take in and release air. Pulmonary

49. function studies are beneficial primarily for determining a
patient’s ability to withstand various types of treatment.
Surgical tests to diagnose NSCLC include sputum cytology,
thoracentesis, fine needle aspiration biopsy and bronchoscopy.
Tumor histology is most frequently obtained through a
fiberoptic bronchoscopy because up to 75% of lesions may be
visible in this fashion. Bronchoscopies are used to help the
doctor find tumors or blockages in the larger airways of the
lungs which are then biopsied during the procedure. During the
procedure, the flexible bronchoscope is passed through the nose
or mouth down into the windpipe and bronchi. Small
instruments are placed down the bronchoscope to take samples
of these tissues which are then examined under the microscope
(American Cancer Society, 2015). The tissue taken from the
biopsy is then sent to the pathology laboratory and examined by
a pathologist.
NSCLC histologies are often classified together although they
are heterogeneous in nature. The most common histologies
include epidermoid or squamous cell carcinoma,
adenocarcinoma and large cell carcinoma. The reason behind
the combination of these heterogeneous histologies is due to the
similar approach in diagnosis, staging, prognosis and treatment
and because they act in a similar fashion clinically overall.
NSCLC T1N0M0 is grouped as a stage 1A non-small cell lung
cancer. The TNM staging system reveals that the primary tumor
is 3cm or less, and it has not extended into the membranes
surrounding the lungs. The primary tumor staging also reveals
that the tumor is surrounded by lung or visceral pleura, and the
tumor lacks bronchoscopic evidence of invasion more proximal
to the lobar bronchus. The regional lymph node status indicates
no regional lymph node metastasis and the distant metastasis
staging indicates no distant metastasis. No grading system is
used to classify this disease.
Multiple modalities used in the treatment of stage 1A NSCLC
include surgery, radiation therapy and adjuvant chemotherapy.
Prior to treatment, the patient’s performance must be evaluated

50. using the Karnofsky scale. Whenever possible, surgery is
recommended as the first treatment route with lobectomy or
segmentectomy depending on the size and position of the tumor
in the chest.
Radiation therapy is at times utilized prior to surgery to reduce
the size of the tumor before the operation or definitively by
patients who are not good candidates for surgery. Radiation
therapy may also be ideal after surgery for patients with
positive margins at the site of resection and for patients who are
high risk for locoregional recurrence. Radiation is also used in
palliative care to elevate symptoms. Radiation therapy can be
used alone or in combination with chemotherapy. Adjuvant
chemotherapy is typically given postoperatively to slow or stop
the growth of the cancer cells which decreases the risk of
relapse of the disease. (Up to Date, 2014).
Common acute side effects of radiation therapy include
dermatitis, erythema and esophagitis. Chronic side effects
usually occur as a result of doses that exceed organ tolerances
and generally include a nonproductive cough, fibrosis of the
lung and subcutaneous fibrosis of the skin. According to the
American Cancer Society as of 2015 the 5-year observed
survival rate for patients who undergo active treatment for stage
1A LLL NSCLC is 49%.
During simulation, the radiation treatment field borders should
include the lesion and margin as well as regional lymph nodes.
For lower lobe lesions, the treatment borders should include the
primary tumor and the entire mediastinum. According to our
text, advanced internal volume localization such as breath
holds, respiratory gating, and CT simulation at full inspiration
and full expiration are helpful in planning. Because critical
organs in the thorax have low tolerance doses and varying tissue
densities, complex strategies such as oblique off-cord
treatments with modifiers such as wedges or tissue
compensators or unequal beam weighing techniques might be
utilized. Small, localized lesions may be treated with dynamic
therapy such as IMRT, stereotactic or tomotherapy.

51. The patient should be positioned to accommodate a complex
treatment plan with their arms raised above the head with the
support of appropriate immobilization devices. According to
our text, prone positioning for lower lobe lesions can facilitate
easy daily setup for off-cord and boost fields. I have never seen
a lung cancer patient treated in the prone position before.
Immobilization devices might include vaclok, wing boards, a
prone pillow support, SBRT full body vaclok for full body
immobilization etc.
Total dose to a lung lesion and margin are typically treated to
50Gy with a beam energy of between 10-12MV if radiation is
adjuvant to surgery or chemotherapy. Total dose to the lung is
typically 45Gy for palliative treatment and 60Gy if radiation is
being used alone. Positive lymph nodes should receive
maximum of the total dose when possible and negative lymph
nodes should receive 45Gy. Conventional fractionation delivers
a daily dose of 180cGy to the total dose over a period of 30-34
days.
1. Please Open the Example Paper, review how it is written.

52. This assignment should be like this example paper, but write
down each point above the each paragraph. Like this:
Epidemiology
Then go on and start writing about this topic until you
move on to the next bullet.
This paper is on Esophagus Adenocarcinoma Distal Segment
(the part that connects to the stomach). It’s in the Cancer TNM
stage of T2N2M0, which I also wrote down in the outline of to
what it means. You can also look it up for more clarity.
2. Follow the Outline I have attached:
Some parts to the outline I have already wrote what needs to be
talked about but do add more if needed. If left blank please find
it. I have also attached PDF files and PPT’s you should use to
complete this assignment. Please look at them all, everything
should be there if not use online sources and reference
correctly.
The PDF with the name Chapter 50 Esophageal Cancer should
have all the information you need.
4. Please e-mail if you have any questions and I’m required to
have 7 pages, thank you.