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KC Esophageal CA case study
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KC Esophageal CA case study
1.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 1 NEOADJUVANT TREATMENT APPROACH TO ESOPHAGEAL CANCER DR. JOE CATES DR. SYED JAFRI DR. KAIDI MIKHITARIAN DR. FRANK SLOVICK
2.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 2 PATIENT R.S. 57 year old male Past Medical History: GERD (requiring ~5 esophageal dilations over 20 years) Hiatal hernia ETOH use (<7 drinks per week) BPH Past Surgical History: Appendectomy (August/2009) Labrum/rotator cuff repair (July/1989) Hernia repair as a child Family History: Maternal grandmother-CRC Father- “some kind of leukemia”
3.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 3 PATIENT PRESENTATION R.S. had endoscopy with esophageal dilation in early December 2014 due to increasing dysphagia Informed that there were no masses/obstructions Developed worsening dysphagia within a few days post endoscopy, PCP ordered upper GI series which revealed esophageal stricture 1/16/15 CT of the Chest, Abdomen and Pelvis Revealed asymmetric thickening of the lower esophagus and/or GE junction, with asymmetry along the outer surface of the esophagus posterolaterally to the left
4.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 4 1/16/15 CT CHEST/ ABDOMEN/ PELVIS (PRE-NEOADJUVANT THERAPY)
5.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 5
6.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 6
7.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 7 PATIENT PRESENTATION CONT. 1/16/15 Underwent endoscopy that showed mass in distal esophagus Biopsy revealed poorly differentiated adenocarcinoma with singet ring cells
8.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 8 1/16/15 EGD BIOPSY PATHOLOGY Poorly differentiated adenocarcinoma with signet ring cells
9.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 9 1/16/15 EGD BIOPSY PATHOLOGY Poorly differentiated adenocarcinoma with signet ring cells
10.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 10 PATIENT PRESENTATION CONT. 1/23/15 Underwent EUS with FNA and stent placement Revealed malignant-appearing esophageal stricture measuring 2 cm in length x 4 mm inner diameter Mass in the gastroesophageal junction measuring up to 10 mm in thickness Three malignant lymph nodes in the middle paraesophageal mediastinum (level 8M) EUS Stage T3 N1 M0
11.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 11
12.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 12
13.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 13 1/23/15 MEDIASTINAL LYMPH NODE, FNA Positive for adenocarcinoma
14.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 14 PATIENT PRESENTATION CONT. 2/5/15 PET/ CT scan revealed activity in the following: Mass in distal third of esophagus At the proximal and distal ends of the esophageal stent Mediastinal lymphadenopathy
15.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 15 2/5/15 PET/ CT (PRE-NEOADJUVANT THERAPY)
16.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 16
17.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 17 NEOADJUVANT APPROACH FOR R.S. Based on EUS staging, pathology and imaging, R.S. was determined to be Stage III and it was decided to place him on neoadjuvant concurrent radiation and chemotherapy 2/11/15: Started concurrent chemotherapy/XRT with weekly Carboplatin AUC 2 and Taxol 3/11/15: Stopped chemotherapy (5 cycles completed) 3/17/15: Ended radiation treatment (25 fractions completed)
18.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 18 RE-STAGING FOR R.S. 3/26/15: CT revealed: Esophageal malignancy traversed by a stent, uncertain as to the extent of the malignancy, which may extend into the proximal stomach. Soft tissue mass causes marked narrowing of the proximal end of the stent Mediastinal adenopathy with indeterminate splenic lesions Small node anterior to the left adrenal gland
19.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 19 3/26/15 CT POST-NEOADJUVANT THERAPY
20.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 20
21.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 21
22.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 22 SURGICAL APPROACH 4/16/15 Transhiatal esophagogastrectomy with gastric pull up and cervical esophagogastrostomy performed by Dr. Cates.
23.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 23 DIAGNOSIS Surgical pathology: Primary Tumor site: Esophagogastric junction (EGJ) Additional sites involved by tumor: none identified Histologic type: Adenocarcinoma Histologic grade: G3 – poorly differentiated Tumor size: greatest dimension 2.2 cm Microscopic tumor extension: tumor invades through the muscularis propria into the periesophageal soft tissue (adventitia) Margins: all margins uninvolved by invasive carcinoma; distance of invasive carcinoma from closest margin 2 mm Treatment effect: present, marked response (grade 1, minimal residual cancer) Regional lymph nodes: 1 involved out of 18 examined Stage: T3 N1 M0
24.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 24 4/17/15 ESOPHAGOGASTRECTOMY SPECIMEN PATHOLOGY Residual poorly differentiated adenocarcinoma
25.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 25 4/17/15 ESOPHAGOGASTRECTOMY SPECIMEN PATHOLOGY Rare isolated tumor cells in 1 of 18 lymph nodes
26.
CONFIDENTIAL AND PROPRIETARY
© 2014 Sarah Cannon. 26 ADJUVANT TREATMENT • Open for discussion ………….
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