Esophagus Final 2003

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Esophageal Cancer Detection / Treatment

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Esophagus Final 2003

  1. 1. James Ratliff, M.D. 07.23.08
  2. 2. <ul><li>C/C: 56 y/o AAF with c/o Difficulty Swallowing </li></ul><ul><li>Patient reports food is getting stuck and she coughs when she drinks water. </li></ul><ul><li>No complaint of nausea/vomiting/hemetemesis </li></ul><ul><li>c/o weakness and severe lethargy </li></ul><ul><li>Associated weight loss approx 9 lbs in 1 week </li></ul><ul><li>She denies fever / chills </li></ul><ul><li>ECOG status 1 </li></ul>
  3. 3. <ul><li>Intraductal Papilloma of Left Breast </li></ul><ul><li>COPD </li></ul><ul><li>Asthma </li></ul><ul><li>Seizure Disorder </li></ul><ul><li>GERD </li></ul><ul><li>Sickle Cell Trait </li></ul>
  4. 4. <ul><li>Left Breast Lumpectomy </li></ul>
  5. 5. <ul><li>Dilantin </li></ul><ul><li>Albuterol </li></ul><ul><li>Thiamine </li></ul><ul><li>Nizatidine </li></ul><ul><li>ALLERGIES: Penicillin </li></ul>
  6. 6. <ul><li>Lives Alone </li></ul><ul><li>Tobacco Use ½ ppd x 30 yrs </li></ul><ul><li>ETOH of 2 Beers Daily </li></ul><ul><li>Denies Drug usage </li></ul>
  7. 7. <ul><li>Mother- Breast Cancer </li></ul><ul><li>Father- Cancer of unknown type </li></ul><ul><li>Brother - Polio </li></ul>
  8. 8. <ul><li>BP 123/71 P 118 R/R 23 T 36.8 </li></ul><ul><li>Gen App: Pt in NAD, AAOX3, Poor Eye Contact </li></ul><ul><li>HEENT: EOMI, MMM, no LAD, + Hirsituism, Poor Dentition </li></ul><ul><li>CVS: S1S2 heard, RRR- tachycardic, no murmurs </li></ul><ul><li>RS: CTA B/L no rhonchi, rales, wheezes </li></ul><ul><li>Abdomen: soft, no rigidity, ND, + Bowel Sounds </li></ul><ul><li>Rectal: heme negative </li></ul><ul><li>Neuro: AxOx3, no focal deficits </li></ul><ul><li>Motor- 5/5 B/L UE, 5/5 B/L LE, 2+ Pulses </li></ul>
  9. 9. UA: wbc 2-5, rbc 0-2, bac -MOD Yeast –FEW (-) nitrite, (+) LE TSH: 0.71 ETOH: (-) Ca: 7.8 Mg: 1.6 Phos: 2.2 Dil:5.5 T. Protein: 5.4 Albumin: 2.5 T. Bili 0.4 Alk Phos: 89 SGOT: 25 SGPT: 11 8.65 11.4 Mcv 89.4 291 139 3.5 109 22 5 0.5 140
  10. 10. <ul><li>Ct Scan of the </li></ul><ul><ul><li>Head </li></ul></ul><ul><ul><li>Neck </li></ul></ul><ul><ul><li>Chest </li></ul></ul><ul><ul><li>Abdomen </li></ul></ul><ul><ul><li>Pelvis </li></ul></ul><ul><li>Video Swallow </li></ul><ul><li>Chest Xray </li></ul>
  11. 11. <ul><li>Invasive Moderately Differentiated Squamous Cell Carcinoma </li></ul>
  12. 12. <ul><li>Pt was kept NPO, evaluated by GI where EGD was performed demonstrating an ulcerative mass - Bx were taken </li></ul><ul><li>Pt was further evaluated by ENT via Triple Scope </li></ul><ul><li>Patient Experienced Respiratory Failure s/p Triple Scope </li></ul><ul><li>Intubated and Transferred to ICU – Successfully Extubated Day2 </li></ul><ul><li>Heme / Onc Recommendation </li></ul><ul><ul><li>Concurrent Chemotherapy / Radiation </li></ul></ul><ul><li>Patient Transferred to Floor -Portacath Placement and Initiation of Therapy </li></ul>
  13. 13. <ul><li>Esophagus is a Cursed Tube </li></ul><ul><ul><li>No Serosa / Thin Walled </li></ul></ul><ul><ul><li>Longitudinal Lesions / Submucosal Lymphnodes </li></ul></ul><ul><li>Squamous Cell / Adenocarcinoma account for over 95% </li></ul><ul><ul><li>In the 1960’s Squamous Cell CA = 90% </li></ul></ul><ul><ul><li>Now Squamous Cell and Adenocarcinoma are about Equal in Occurrence </li></ul></ul><ul><li>50% - 60% present with Incurable Locally Advanced / Metastatic Disease </li></ul><ul><li>6000 New Cases per Year </li></ul><ul><li>Male to Female Ratio 3:1 </li></ul><ul><li>Black to White Ratio 6:1 </li></ul>
  14. 14. Squamous Cell Adenocarcinoma In Burma In Chicago
  15. 15. <ul><li>Palliation is the Goal of Treatment for the Majority </li></ul><ul><li>Tumors that Invade through the Esophageal Wall or are Node + </li></ul><ul><ul><li>Long Term Survival is Poor </li></ul></ul><ul><ul><li>Optimal Treatment for T3 and Above, if Unresectable, is Combination Chemoradiotherapy </li></ul></ul><ul><ul><li>Accurate Staging is the Key </li></ul></ul><ul><li>Barium studies Suggest the Diagnosis </li></ul><ul><li>Diagnosis is Made with a Biopsy </li></ul><ul><li>Accuracy Improves with the Frequency of Biopsies taken </li></ul><ul><ul><li>1 = 93% </li></ul></ul><ul><ul><li>4 = 95% </li></ul></ul><ul><ul><li>7 = 98% </li></ul></ul><ul><li>Addition of a Brush Cytology increases Accuracy to 100% </li></ul>
  16. 16. <ul><li>5% to 6% of Esophageal Cancers </li></ul><ul><li>Locally Advanced Disease Typically Present at DX </li></ul><ul><li>Radical Neck Dissection is Often Performed </li></ul><ul><ul><li>Requires Removal of Portions of the Pharynx, Larynx, Thyroid, Proximal Esophagus </li></ul></ul><ul><ul><li>Permanent Terminal Tracheostomy </li></ul></ul><ul><ul><li>Gastric Pull-Up for Restoration of the GI Tract </li></ul></ul><ul><ul><li>Survival is Roughly the Same as Chemoradiotherapy </li></ul></ul><ul><ul><li>10 year Survival is 27% </li></ul></ul>
  17. 17. <ul><li>Stage 0 - Carcinoma In Situ </li></ul><ul><li>Stage I – Invades Mucosa / Submucosa / Lamina Propria / </li></ul><ul><li>Stage II A–Invades Muscularis Propria / Adventitia </li></ul><ul><li>Stage IIB - Invades Mucosa / Submucosa / Lamina Propria with Lymph Node Involvement </li></ul><ul><li>Stage III – Invades Adventitia with Regional LN Involvement or Invasion of Adjacent Structures regardless of LN Involvement </li></ul><ul><li>Stage IV – Any Distant Metastasis </li></ul><ul><li>Stage IV A– Any Distant Metastasis to Cervical Nodes </li></ul><ul><li>Stage IV B– Any Distant Metastasis to Other Distant Sites </li></ul>
  18. 18. <ul><li>T </li></ul><ul><li>M </li></ul>N
  19. 20. <ul><li>M/C sites for Squamous Cell CA’s of the Esophagus are Intrathoracic </li></ul><ul><li>CT </li></ul><ul><ul><li>Limited ability to identify Locally Advanced Diseased </li></ul></ul><ul><ul><li>Nodal Mets in the Region of the Celiac Axis </li></ul></ul><ul><ul><li>Subclinical Distant Mets – Peritoneal Cavity </li></ul></ul><ul><li>PET </li></ul><ul><ul><li>More Sensitive than CT or EUS </li></ul></ul><ul><ul><li>Identifies Distant MET’s more effectively and Eliminates Needless Surgery </li></ul></ul><ul><ul><li>Drawback is Poor Spatial Resolution </li></ul></ul><ul><li>Endoscopic Ultrasound with FNA </li></ul><ul><ul><li>Primary Modality for Celiac Nodes </li></ul></ul><ul><ul><li>Used for Evaluation of Liver Mets < 1 cm +/- Ascites </li></ul></ul><ul><li>Diagnostic Laproscopy </li></ul><ul><ul><li>Helpful for Liver Intra-abdominal Space / GE Junction Cancers </li></ul></ul><ul><ul><li>Considered Optional if no evidence of M1 Disease </li></ul></ul>
  20. 22. <ul><li>DEFINITIVE TREATMENT </li></ul><ul><li>PALLIATIVE TREATMENT </li></ul>
  21. 23. <ul><li>DEFINITIVE TREATMENT </li></ul><ul><li>PALLIATIVE TREATMENT </li></ul>
  22. 24. <ul><li>Represents 60% of Patients with Esophageal Cancer </li></ul><ul><li>Major Goal is Palliative and Restoring the Ability to Swallow </li></ul><ul><li>Systemic Chemotherapy +/- Radiation </li></ul><ul><ul><li>Often Temporarily Relieves Dysphagia </li></ul></ul><ul><ul><li>Small but Real Chance of Sustained Disease Control and Survival </li></ul></ul>
  23. 25. Weeks 1,5,8,11 Modified Approach: Docetaxel + Carboplatin + RT Role for Benzodiazepines @ Bedtime – Esophagitis Zinc Supplements to Prevent / Delay Esophagitis Herskovic Regimen
  24. 26. NCCN Practice Guidelines in Oncology – v.1.2008 <ul><li>Palliative Therapy - Category 1 Consensus </li></ul><ul><ul><li>Concurrent Chemoradiation </li></ul></ul><ul><ul><li>5FU Based / Cisplatin </li></ul></ul><ul><ul><li>50.4 Gy RT </li></ul></ul><ul><ul><li>And / or Best Supportive Care </li></ul></ul><ul><li>Conroy Yataghene Phase II Trial - Journal of Clinical Oncology 2007;25(18suppl)4532 </li></ul><ul><ul><li>5-FU / Leucovorin / Oxaliplatin (FOLFOX4) vs 5-FU / Cisplatin </li></ul></ul><ul><ul><li>Median Time to Progression 15m – 9.5m </li></ul></ul><ul><ul><li>Median Event Free Survival 11.6m – 7.8m </li></ul></ul><ul><ul><li>Median Overall Survival 22.7 m – 14.7m </li></ul></ul><ul><li>Phase III is Underway </li></ul>
  25. 27. <ul><li>Important in the Management of Unresectable Esophageal Cancer </li></ul><ul><ul><li>Maintenance of Long Term Disease Control </li></ul></ul><ul><ul><ul><li>Sustained Remission / LT Survival Rare with RT alone </li></ul></ul></ul><ul><ul><ul><ul><li>RT alone has a 1-2 % 3 to 5 year Survival Rate </li></ul></ul></ul></ul><ul><ul><ul><ul><li>In the RTOG Trial All Patients in the RT Only Arm Were Dead byYr 3 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>27% of those in the Chemoradiotherapy Arm were Alive at Yr 5 </li></ul></ul></ul></ul><ul><ul><li>Significant Dysphagia Palliation is Possible with RT </li></ul></ul><ul><ul><ul><ul><li>70% to 90% Palliated for an Average of 3 Months </li></ul></ul></ul></ul><ul><ul><ul><li>Downside is the Time it Takes to Accomplish -5 to 6 weeks </li></ul></ul></ul>
  26. 28. <ul><li>Risk of Transesophageal Fistula Development </li></ul><ul><ul><li>6% Risk </li></ul></ul><ul><ul><li>70 % Close Spontaneously after Treatment </li></ul></ul><ul><li>Post RT Strictures </li></ul><ul><ul><li>Malignant and Benign </li></ul></ul><ul><li>Recurrent Dysphagia </li></ul>
  27. 29. <ul><li>RTOG 85-10 Trial </li></ul><ul><ul><li>Demonstrated a significant Survival Benefit to Concurrent Chemo Radiotherapy </li></ul></ul><ul><ul><ul><li>Median Survival of 14 vs 9 Months </li></ul></ul></ul><ul><ul><ul><li>5 Year Survival of 27% vs 0% </li></ul></ul></ul><ul><ul><li>Relief of Dysphagia </li></ul></ul><ul><ul><ul><li>88% Reported Improvement in 2 Weeks </li></ul></ul></ul><ul><ul><ul><li>Maximum Benefit in 4 Weeks </li></ul></ul></ul><ul><ul><ul><li>All had No Significant Dysphagia Until Death or Last Followup Visit </li></ul></ul></ul><ul><ul><li>Failure Rate of 45% </li></ul></ul><ul><li>Intergroup Trial 0123 Showed No Benefit to HiDose RT </li></ul><ul><li>Chemoradiotherapy Alone = to Chemoradiotherapy followed by Surgery </li></ul><ul><li>Chemoradiotherapy Associated with More Local Failures 40% - 50% </li></ul>
  28. 30. <ul><li>High Radiation Dose with Relative Sparing of Surrounding Structures </li></ul><ul><li>Used Alone or With EBRT + - Chemo </li></ul><ul><li>Alternative to Stent Placement – Dysphagia </li></ul><ul><li>Administered at a Low Dose vs High Dose Rate </li></ul><ul><li>Can Provide Long Term Palliation </li></ul><ul><ul><li>Longer to Act Compared to Metal Stent </li></ul></ul><ul><ul><li>Increased Days with No Dysphagia - 115 vs 82 </li></ul></ul><ul><ul><li>Lower Complication Rate </li></ul></ul><ul><ul><li>Better Quality of Life Scores </li></ul></ul><ul><li>Brachytherapy Boost + RT + Chemo Mixed Results in Trials </li></ul><ul><ul><li>2 Studies Showed the Combo to be Tolerated – Survival 17 / 16.5 Mon </li></ul></ul><ul><ul><li>RTOG Study - 34% Incidence of Severe Toxicity or Death – 11 mon </li></ul></ul><ul><li>Best Used in Short Survival Patients - 3 to 6 Months </li></ul><ul><li>If Survival is Less then 3 Months Stenting is Advised </li></ul>
  29. 31. <ul><li>http://www.nccn.org/professionals/physician_gls/PDF/esophageal.pdf -v.1.2008 </li></ul><ul><li>http://www.uptodate.com/online/content/topic.do?topicKey=gicancer/11551&view=print </li></ul><ul><li>http://ctep.cancer.gov./forms/CTCAEv3.pdf </li></ul><ul><li>Herskovic, A, Martz,K,Al-Sarraf, M, et al. Combined chemotherapy and radiotherapy compared with radiotherapy alone in patients with esophageal cancer of the esophagus. N Engl J Med 1992; 326: 1593 </li></ul><ul><li>Chu, Edward, Chemotherapy Protocols. Jones and Bartlett Pub 2007 ISBN – 13:978-0-7637-4454-0 </li></ul>

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