Case Number: RT (M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor

Transcription

1 Squamous Cell Carcinoma with Sarcomatoid Differentiated of the Esophagus with a ct3 Classification: the Role and Treatment Consideration of Radiotherapy Case Number: RT (M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor Purpose: to present a case with squamous cell carcinoma with sarcomatoid differentiated of the esophagus with ct3 classification; to discuss the role and treatment consideration of radiotherapy 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 74 year-old male patient, 黃 OO, was referred to us for radiotherapy assessment for esophagus cancer. S: 1. In 2008/01, he started to suffer from dysphagia, poor oral intake, and vomiting after oral feeding. 2. In 2008/02, upper GI pan-endoscope was done, and an annular tumor over the upper third esophagus was found. Biopsy was done and pathology reported squamous cell carcinoma. 3. On 2008/3/12, you visited this patient and his son in the ward. Histories: heavy smoker and drinker for several decades; NDKA; no major disease history. Review of systems: body weight loss near 10 Kg in recent one month; poor oral intake and poor oral feeding O: 1. General Condition: ECOG: 2-3, sitting on bed, speech: relatively OK, heavy hearing impairment, bilateral ears 2. Physical Examinations: (1). HEENT & SCF: no SCF LNs; (2). CHE: neg.; (3). ABD: no tenderness; (4). Back & Spine: no knocking pain; (5). Extremities: muscle power OK, no numbness; (6). Others: neg. 3. ***Pathology in 2008/03, esophagus, 21 cm from incisor, biopsy: squamous cell carcinoma, poorly differentiated, with sarcomatoid differentiated or sarcomatoid carcinoma. 4. Images: (1). Upper GI pan-endoscope in 2008/02: an annular tumor over the 21 cm from the incisor with narrow lumen. (2). CXR in 2008/02: bilateral lung diffuse infiltrating lesions. (3). Chest CT: pending result 5. Others: neg.

2 Key Image(s): Fig. 1. Fig. 2. Fig. 3.

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)? 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 are your Oncology Diagnosis / Assessments 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.)

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. Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? A2: ct3(significant wall thickness; clinically suspect T3)N1(mediastinum LNs)M0, stage III (2008/02, AJCC 2002) Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? A3: No pathology stage can be defined in this case now. Q4: What are your Oncology Diagnosis / Assessments for this case? A4: Oncology Diagnosis: Squamous cell carcinoma, poorly differentiated (Gr. III) with sarcomatoid differentiated, of the esophagus, 21 cm from the incisor (upper third), ct3(significant wall thickness; clinically suspect T3)N1(mediastinum LNs)M0, stage III (2008/02, AJCC 2002). Q5: What is your Oncology Plan for this case? A5: Suggest Current Oncology Plan: pre-operative CCRT then assessment a planned surgery if possible. 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: ct3n1m0, stage III, esophagus cancer; RT in neo-adjuvant CCRT setting for preparing radical surgery if possible. (2). Goal: potentially curative in pre-operative neo-adjuvant CCRT setting (3). Target & Volume: primary tumor and LN drainage region (4). Technique: 3DCRT (5). Dose & Fractionation: 4500 cgy in 25 fractions Further Readings & References: NCCN 2009 & Perez 2008 & AJCC 2006 Radiation Oncologist Hon-Yi Lin 2009/05/17

5 Key Image(s): (with marked) Fig. 1. Fig. 1. Significant wall thickness with a small residual lumen of the esophagus was found, c/w esophagus cancer (as the white arrow). Fig. 2. Fig. 2. The esophagus shows lumen dilatation with fluid accumulation and some degree of wall thickness in this cut of chest CT (as the long white arrow); some small LNs were found over the mediastinum (as the short white arrows). Fig. 3. Fig. 3. The esophagus that was over the upper level of obstructive site secondary to esophagus tumor shows lumen dilated with fluid accumulation (as the long white arrow); some small LNs were found over the mediastinum (as the short white arrows); Port-A tube was found inside the superior vena cava (as the white arrow head).