How to Manage Esophagus Cancer Patients with ct3n0m0, stage III Disease?

Transcription

1 How to Manage Esophagus Cancer Patients with ct3n0m0, stage III Disease? Case Number: RT (M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor Purpose: to present a case of esophagus cancer, ct3n0m0, stage III, and to discuss the possible oncology managements Scenario: You are radiotherapy (RT) Intent Doctor/Special Nurse/Resident Doctor, and you are assigned to evaluate the following patient before visiting of your RT attending physician. Please review the following description carefully; your RT attending physician will visit this patient later and discuss with you after your review. Case Presentation: This 63 year-old male patient, 李 OO, was referred to us for radiotherapy assessment of Esophageal cancer (M/3), T3N0M0 at 嘉義長庚醫院, for assessment of patient s chose of CCRT then operation. S: 1. One month ago, he started to suffer from dysphagia. 2. In 2008/08, he came to LMC for evaluating. Esophagus tumor was found. Biopsy was done and pathology reported malignancy. 3. In 2008/08, he came to our hospital for further management. After work-up studies, esophagus cancer, ct3n0m0, stage III, was staged. Neoadjuvant CCRT then assessment of OP was planned for further management. 4. On 2008/09/09, you visit this patient and his wife in the ward. Histories: type 2 DM and gout with regular treatment; drinking history and smoking history were told. Review of systems: dysphagia still now O: 1. General Condition: ECOG: 1 (dysphagia), ambulatory status, on chemotherapy now, speech: OK 2. Physical Examinations: (1). HEENT & SCF: no neck LNs (2). CHE: neg. (3). ABD: no tenderness (4). Back & Spine: no knocking pain (5). Extremities: free movement (6). Others: neg. 3. ***Pathology: no pathology report available at visiting. 4. Images: (1). CT chest in 2008/08: pending result. (2). CXR in 2008/08: neg. (3). Bone scan in 2008/08: neg. (4). PET/CT in 2008/08: pending formal report. 5. Others: neg.

2 Key Image(s): Fig. 1. Chest CT Fig. 2. Panel A. Whole body PET/CT Fig. 2. Panel B. PET/CT

3 Questions & Discussions: (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? (After your RT attending physician discussed with the radiologist and Nuclear Medicine Dr. by telephone, the radiologist and Nuc Dr. confirmed preliminarily that no distant metastases were found based on the chest CT films and the PET/CT films, including lung to lung, liver, ribs & spine, and adrenal glands. No clinically significant lymph node over the mediastinum was also found. Please further answer the following questions.) Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? Q4: What is your Oncology Diagnosis for this case? Q5: What is your Oncology Plan for this case? Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.) Q7: If this patient had medical unfit condition for operation (such as severe heart disease), does your oncology plan change?

4 Questions & Discussions: (with potential answers) (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? A1: As described in the last attached page. (After your RT attending physician discussed with the radiologist and Nuclear Medicine Dr. by telephone, the radiologist and Nuc Dr. confirmed preliminarily that no distant metastases were found based on the chest CT films and the PET/CT films, including lung to lung, liver, ribs & spine, and adrenal glands. No clinically significant lymph node over the mediastinum was also found. Please further answer the following questions.) Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? A2: ct3n0m0, stage III (AJCC 2006, 2008/08) Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? A3: no pathology status can be defined at this time due to no major surgery now. Q4: What is your Oncology Diagnosis for this case? A4: Esophagus cancer (histological type? need to be re-checked), M/3, supra- and infra-carina region, ct3n0m0, stage III (AJCC 2006, 2008/08), on chemotherapy now Q5: What is your Oncology Plan for this case? A5: Planned CCRT then OP Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.) A6: RT Plan may be designed as the following one: (1). Indication: ct3n0m0, stage III (2). Goal: curative in pre-op CCRT setting (3). Target & Volume: gross tumor and limited LN-drainage area with adequate margin (4). Technique: 3DCRT (5). Dose & Fractionation: 4500 cgy in 25 fractions Q7: If this patient had medical unfit condition for operation (such as severe heart disease), does your oncology plan change? A7: If medical unfit for major surgery, the oncology plan of pre-op CCRT then OP may be shifted to definitive CCRT if no noted contra-indications, or shifted to definitive RT alone if chemotherapy cannot be given. Further Readings & References: NCCN 2009 & AJCC 2006 Radiation Oncologist Hon-Yi Lin 2009/01/17

5 Key Image(s): (with marked) Fig. 1. Chest CT Fig. 1: the primary tumor over the esophagus, M/3, was seen, which with significant wall thickness with a residual small lumen (as the black arrow); a small LN with size less than 2 mm over the peri-esophagus region (as the short white arrow); a very high density of aorta/artery vessel system means that a arterial phase of contrast in this set of chest CT (as the long white arrow). Fig. 2. Panel A. Whole body PET/CT Fig. 2. Panel A. Only the primary tumor over the esophagus, M/3, was noted in the whole body PET/CT films; no clinical meaningful distant metastases could be identified (as the black arrow). Fig. 2. Panel B. PET/CT Fig. 2. Panel B. Cross-section image of the PET/CT was compatible with high-increased-uptake esophagus tumor without noted associated LNs (as the long white arrow); a weakuptake was found on the left hilar LNs, which may be due to inflammatory status and not related to the esophagus lesion.