Running head: ESOPHAGUS ADENOCARCINOMA T2N2M0 1 ESOPHAGUS ADENOCARCINOMA T2N2M0 9 Esophagus Adenocarcinoma T2N2M0 Adenocarcinoma is a complication of the gastroesophageal reflux that affects the distal esophagus. Out of an estimated 12,500 cases diagnosed in 2000 there were 12,200 deaths. Therefore, the mortality rate is rather high for this type of cancer. According to the National Center for Biotechnology Information this type of cancer is currently ranking seventh in the list of the most common cancers in the world (Lerut, 2001). The cancer affects those who are in there mid to late adulthood and only 8% of those who are diagnosed with this disease survive. Mostly, the differences in survival are based on racial background, sex, and histological type, which means the kind of cancer that affects an individual. Anatomy Esophagus is a thin-walled, hollow tube, measuring at about 25 cm in length. Squamous cell carcinoma for the proximal to mid esophagus and adenocarcinoma for the distal end of the esophagus. The esophagus is roughly from C6 to T11 it is also divided into four regions. These regions are the Cervical, Upper thoracic, Mid thoracic & Lower thoracic. The Lower thoracic is where this patients Cancer is located. The lymphatics in this area are the Lower peri-esophagogastric lymph node below the level of the azygos vein, the diaphragmatic, peri-cardiac, left peri-gastric and celiac nodes. Epidemiology Regarding gender, the cancer of the esophageal 2.7 more commonly found in men than women and more lethal. Concerning the issue of age and the incidence of the disease, it peaks most in the 7th decade in patient’s life. With adenocarcinoma white males ranging in the age of 40 to 50 are mostly affected (Zhang, 2013). In fact, 20% of death rates in the United States among men are caused by adenocarcinoma. In 2012, the National Cancer Institute speculated that out of 17,460 persons diagnosed with cancer of the esophagus, 15,070 would die. Based on the fact that the cancer affects men more than women it was estimated that the cancer would affect 13,950 men and 3,510 women that year. However, the United States is not the only country affected by adenocarcinoma. The rates are much higher in China. Chronic alcohol uses, as well as external carcinogens, have been pinpointed as the main causes of adenocarcinoma (Zhang, 2013). Additionally, there have been instances in which nutrition has been raised as a factor leading to the problem; however, diet does not explain the origin of the cancer well. Specialists claim that if the cancer can be related to diet, then it would be much easier for the disease to be averted by changes in eating patterns. Regarding the issue of race in America, incidences of whites getting the adenocarcinoma is more common than that of blacks (Baquet CR, 2015), due to poor eating habits, diet, status and exposure to alcohol and external carcinogens. Inherently, smokers have an increased risk of getting the esophagus adenoca.

1. Running head: ESOPHAGUS ADENOCARCINOMA T2N2M0
1
ESOPHAGUS ADENOCARCINOMA T2N2M0 9
Esophagus Adenocarcinoma T2N2M0
Adenocarcinoma is a complication of the gastroesophageal
reflux that affects the distal esophagus. Out of an estimated
12,500 cases diagnosed in 2000 there were 12,200 deaths.
Therefore, the mortality rate is rather high for this type of
cancer. According to the National Center for Biotechnology
Information this type of cancer is currently ranking seventh in
the list of the most common cancers in the world (Lerut, 2001).
The cancer affects those who are in there mid to late adulthood
and only 8% of those who are diagnosed with this disease
survive. Mostly, the differences in survival are based on racial
background, sex, and histological type, which means the kind of
cancer that affects an individual.
Anatomy
Esophagus is a thin-walled, hollow tube, measuring at about 25
cm in length. Squamous cell carcinoma for the proximal to mid
esophagus and adenocarcinoma for the distal end of the
esophagus. The esophagus is roughly from C6 to T11 it is also
divided into four regions. These regions are the Cervical, Upper
thoracic, Mid thoracic & Lower thoracic. The Lower thoracic is
where this patients Cancer is located. The lymphatics in this
area are the Lower peri-esophagogastric lymph node below the
level of the azygos vein, the diaphragmatic, peri-cardiac, left
peri-gastric and celiac nodes.
Epidemiology
Regarding gender, the cancer of the esophageal 2.7 more
commonly found in men than women and more lethal.
Concerning the issue of age and the incidence of the disease, it
peaks most in the 7th decade in patient’s life. With
adenocarcinoma white males ranging in the age of 40 to 50 are
mostly affected (Zhang, 2013). In fact, 20% of death rates in the

2. United States among men are caused by adenocarcinoma. In
2012, the National Cancer Institute speculated that out of
17,460 persons diagnosed with cancer of the esophagus, 15,070
would die. Based on the fact that the cancer affects men more
than women it was estimated that the cancer would affect
13,950 men and 3,510 women that year. However, the United
States is not the only country affected by adenocarcinoma. The
rates are much higher in China. Chronic alcohol uses, as well as
external carcinogens, have been pinpointed as the main causes
of adenocarcinoma (Zhang, 2013).
Additionally, there have been instances in which nutrition
has been raised as a factor leading to the problem; however, diet
does not explain the origin of the cancer well. Specialists claim
that if the cancer can be related to diet, then it would be much
easier for the disease to be averted by changes in eating
patterns. Regarding the issue of race in America, incidences of
whites getting the adenocarcinoma is more common than that of
blacks (Baquet CR, 2015), due to poor eating habits, diet, status
and exposure to alcohol and external carcinogens. Inherently,
smokers have an increased risk of getting the esophagus
adenocarcinoma.
Etiology
There is a direct connection between the length of time one
smokes, how many cigarettes they smoke in a day and the risk
of getting esophageal cancer. Research has suggested that a
smoker ingests tobacco condensates that cause nitrosamines that
come into contact with the esophageal mucosa. This affects the
lining of the esophagus and subsequently leads to
adenocarcinoma. Therefore, the main risk factors are excessive
alcohol abuse as well as excessive smoking (Zhang, 2013).
Additionally, high-fat diet, low-calorie diet, and low protein
intake increased risk of getting cancer of the esophagus. Acid
reflux caused by excessive use of alcohol and cigarettes, as well
as diet, begins the process of damage to the esophagus that may
lead to the formation of this deadly cancer. Furthermore,
obesity increases the risk of GERD or gastroesophageal reflux;

3. which in turn increases the risk of esophagus cancer. The ratio
of male to female risk in getting this cancer is 7:1, whereas the
ratio for black to white in terms of race is 1:4. However,
Barrett’s esophagus increases the risk factor by 30% to 60% or
more.
Detection and Diagnosis
Prior to any treatment, staging and classification, the patient’s
history and physical examination has to be retrieved. When
looking at the TNM staging for this disease the T staging
involves echo-endoscopy (EUS) and CT scan of the major blood
vessels, the vertebrae, and tracheal bronchial tree. N staging
entails clinical examination of the cervical nodes. This is done
because results from the CT scan only produce 60% accuracy
for results in the mediastinal lymph node invasion. M staging
involves liver ultrasound, chest X-ray and ultrasound of the
neck. In this type of staging, a CT scan of the abdomen and
chest provide for detection of distal lymph node metastasis and
visceral metastasis. Tumor markers such as HER2 are usually
performed on biopsy samples obtained by FNA (fine-needle
aspiration). Immunohistochemistry is used to measure the
amount of HER2 protein present in the sample. PET scan
(Positron Emission Tomography) has also been introduced to
additional possibilities in detection of visceral organ metastasis
as well as distant lymph node metastasis (Lerut, 2001).
Natural History of the Disease
According to Perez and Brady's principles and practice of
radiation oncology the natural history of this disease is
squamous cell carcinoma for the proximal to mid esophagus and
adenocarcinoma for the distal end of the esophagus. Which is
extensive local growth with lymph node metastases. The fact
that the esophagus has no covering serosa, direct invasion of
contiguous structures occur early (Halperin, 2008, p. 1133).
Tumors in the lower third of the esophagus such as this disease
can evade the pericardium or aorta that consequence to
mediastinitis, which is the inflammation of the cellular tissue of
the mediastinum, you also see massive hemorrhage, or empyema

4. (collection of pus in body cavity). Considering this disease
being of a T2 lesion, the report incidence of nodal spread is
38% to 60%. Also at presentation for lower esophageal and
gastroesophageal junction adenocarcinomas such as this disease,
70% of patients will have nodal metastases (Halperin, 2008).
Esophageal adenocarcinoma T2N2M0, this cancer has grown
into the layer below the epithelium, such as the muscularis
mucosa, which is a thin layer of muscle of the gastrointestinal
tract.
Pattern of Spread
The anatomy of the tumor begins from the inferior pulmonary
vein to the lower thoracic vein or esophagogastric junction
(EGJ). The lymphatics part of the anatomy can be found in the
abdominal nodes and celiac nodes. These are the areas used for
testing for cancer as the infection first shows itself in this
lymphatic system.
Clinical Presentation
Primarily, symptoms for the esophagus adenocarcinoma alert
the patient when the disease is in an advanced stage. Therefore,
it is necessary that the diagnosis be done at an early stage.
Dysphagia is a common symptom that entails the narrowing of
the esophageal lumen by a third of the average size. Weight loss
is also a common sign of this cancer as the patient reduces
about 10% of their normal weight. In case one suffers from a
cough when they try and swallow, this results from the cancer
extending to the trachea and the outcome is trachea-esophageal
fistula. Extra-esophageal spread may also cause pain that
radiates to the back, and this also causes hoarseness due to the
laryngeal nerve involvement (Zhang, 2013).
Histopathology and Staging
Esophagus T2N2M0 adenocarcinoma is a stage IIIA
cancer. The primary tumor is growing into the thick muscle
layer (muscularis propria). The cancer has now spread to three
to six nearby lymph nodes. When it comes to distant organs or

5. lymph nodes the cancer has not metastasized.
Simulation and Treatment Principles and Practice
Looking at the radiation treatment field borders in simulation
for esophagus adenocarcinoma a margin of 5cm above and
below the tumor is usually recommended, also for diseases
located in the lower esophagus such as this one, the inferior
margin of the initial fields includes the celiac axis nodal basins
as well as gastrohepatic ligament. Celiac axis is located at the
level of T12 and can be identified on CT (Halperin, 2008).
Patient should be positioned supine, with both arms raised to
accommodate lateral or posterior oblique fields for spinal cord
sparing. Immobilization devices include wing board, vac-lok
and knee bolster for knee support. The book mentioned that the
patient could also be positioned prone for a slight displacement
of esophagus away from thoracic spine (Halperin, 2008). I never
seen an esophagus cancer patient treated in a prone position
Initial fields include AP/PA and are treated to 30 to 36 Gy after
which oblique fields may be used which include anterior field
with posterior oblique pair or opposed right anterior and left
posterior oblique fields to 45 Gy, including of the nodal basins.
Additionally attention should be given to avoid as much of the
heart as possible and the kidney volume in the radiation should
be considered when treating the celiac axis in lower esophageal
tumors. Total dose to esophagus using Chemoradiation (EBRT)
followed by surgery is typically 45-50 Gy over five week using
(Halperin, 2008).
Dose Limiting Critical Structures (Tolerance Doses)
Organ
Injury
TD 5/5 (cGy)
Lung
Pneumonitis
1750
Spinal Cord
Myelitis/Necrosis
4500

6. Liver
Liver failure
3000
Kidney
Nephritis
2300
Heart
Pericarditis
4000
Multimodality Treatment Approach
According to the NCCN guidelines patients with locally
advanced esophagus cancers do best if they have Preoperative
Chemoradiation followed by Surgery. A study in the New
England Journal, published in 2012 demonstrated the value of
this. In this study they randomly assigned patients with
resectable tumors to receive surgery alone or chemoradiation
followed by surgery. The results where better in the patients
that had chemoradiation flowed by surgery than those who had
surgery alone (Miller, 2014). Additional treatments for
adenocarcinomas include lymphadenectomy, which has raised
controversy from various specialists though known to increase
the survival chances for patients with esophageal cancer.
Chemoradiation has a 4-11% mortality rate with a survival rate
of about 29 months. Additionally, there is a 5-year survival rate
of 34%. In general there is 25-35% number of patients with no
residual tumor after this procedure. Fundamentally,
Chemoradiation followed by surgery has shown superiority to
surgery alone in various case studies done on 113 patients who
had adenocarcinoma, and it was found that the survival rate was
3-years but at a 32% versus 6% for Chemoradiation and surgical
treatment respectively (Zhang, 2013).
Palliative treatment is frequently used to relieve esophageal
adenocarcinoma symptoms, especially, dysphagia. Surgical
palliation usually entails reconstruction and resection and if
possible the removal of a bulk of the disease. This prevents

7. fistula and abscess formation as well as bleeding. However,
there is a poor prognosis for patients with advanced cases and
morbidity that is related to the resection; as such this approach
is avoided for patients that can be managed with non-surgical
modalities (Lerut, 2001). The extent of the resection depends on
the size of the primary tumor nature of the procedure and the
histology or type of cancer that the tumor is associated with.
Primarily, for tumors that are found to have extensive Barrett's
esophagus, total esophagectomy combined with cervical
anastomosis help achieve disease-free margins. For abdominal
esophagus that contains distal lesions, intra-thoracic esophageal
anastomosis done just above the azygos vein is adequate.
However, most surgeons prefer to perform total esophagectomy
(Lerut, 2001).
Some common acute reaction to radiation is mainly dysphagia,
onset at about 20 Gy. Chemoradiation intensifies dysphagia and
lowers onset dose. Chronic late complications from radiation
therapy include perforation, hemorrhage from tumor dissolution,
stricture, lung necrosis, and pneumonitis. The National Cancers
Institute’s Surveillance states that the 5-year survival rate for
cancer of the esophagus in the regional stage is 21%.
Conclusion
In conclusion, the discussion has gone through the causes of
adenocarcinoma, the risk factors, the signs, and symptoms as
well as a few of the tested medical procedures used in treatment
or alleviation of this cancer. There are still additional
treatments under research that have not been highlighted in this
study. The discussion has shown that the main difficulty in
treatment of adenocarcinoma is the fact that early detection is
next to impossible. Therefore, the main areas of research for
treatment are looking into ways for early detection of this
cancer in areas that are not considered high risk and do not
require constant screening processes before the cancer is
beyond treatment.

8. Reference:
Baquet CR, e. (2015). Esophageal cancer epidemiology in
blacks and whites: racial and gen. - PubMed - NCBI.
Ncbi.nlm.nih.gov. Retrieved 19 March 2015, from
http://www.ncbi.nlm.nih.gov/pubmed/16334494/
Halperin, E. (2008). Chapter 50 Esophageal Cancer. In Perez
and Brady's principles and practice of radiation oncology (5th
ed., p. 1133). Philadelphia: Wolters Kluwer Health/Lippincott
Williams & Wilkins.
Google Docs,. (2015). Esophagus cancer. Retrieved 19 March
2015, from
https://docs.google.com/presentation/d/1Gzz3W4e5gUtXe7ov7R
BT0m3SSbMlfM9-fv2LBgGS5e4/present#slide=id.i32
Lerut, T. (2001). Carcinoma of the esophagus and gastro-
esophageal junction. Zuckschwerdt. Retrieved from
http://www.ncbi.nlm.nih.gov/books/NBK6982/
Miller, R. (2014). Esophagus Cancer. Retrieved March 22,
2015, from

9. http://www.aboutcancer.com/esophagus_cancer_intro.htm
Zhang, Y. (2013). Epidemiology of esophageal cancer.WJG,
19(34), 5598. doi:10.3748/ wjg.v19.i34.5598
Required sections for written assignment forRetinoblastoma
Stage IIIa
Only focus on Stage IIIa for Retinoblastoma when writing from
Natural history of Disease down….
8 Full pages from top to bottom NOT including cover or
Reference page. APA format no need for big words just be clear
with great flow.
Opening overview
Anatomy
Epidemiology
Etiology
Detection and Diagnosis
Natural history of the Disease
Pattern of spread
Clinical presentation
Histopathology and Staging
- You do not need to go into great detail on some of the areas
such as histopathology and staging, just say what it is. As an
example when you discuss the stage only include what it takes
to be classified for the stage of the disease that you are writing
about not about all of the other stages that the disease could be
classified as.
Simulation and Treatment Principles and Practice
-Explanation of the procedure, immobilization and positioning
devices, CT process, documentation, patient education
Dose Limiting Critical Structures
-I showed you an example in the Example Paper; basically what
will be around the Treatment Field when being treated; I’ll find

10. the tolerance doses just input the structures.
Multimodality Treatment Approach
-Treatment technique, treatment dose, prescription scheme,
beam arrangement/ planning options, beam type (photons,
electrons etc.), energy of the beam, patient education, acute and
chronic side effects.
Conclusion