8 Page Paper

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 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; 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 (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 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
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 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.

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/1Gzz3W4e5gUtXe7ov7RBT0m3SSbMlfM9-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 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