54 yearold woman with newly diagnosed esophageal cancer

54 -year-old woman with newly diagnosed esophageal cancer Associate Professor, Dr. Umut Kefeli, Kocaeli University School of Medicine Department of Medical Oncology 8 th International Gastrointestinal Cancer Conference 07. 12. 2018

Case Presentation q 54 -year-old q♀ q 2 children q ECOG PS 0 q Hypothyroidism q No history of smoking, alcohol q. Dysphagia

• Upper GIS endoscopy: Thoracal esophageal stricture at nearly 35 cm from the incisors. • Thorax CT: 40 mm long irregular wall thickening at distal thoracic esophagus, nearly totally obliterating the lumen which suggests an esophageal mass.

• Thorax CT: - Mass lesion causes indentations of the right pulmonary artery and the posterior contour of the left atrium. - No clear fat plane between descending aorta and the mass lesion. - Prevascular, paratracheal and right paraesophageal, 14 x 7 mm. lymphadenopathies. - Right lung parenchymal, up to 4. 5 mm three pulmonary nodules and 2 mm subpleural nodule at left lower lobe.

• PET/CT: - 37 mm long, infracarinal esophageal wall thickening (SUVmax: 32) - Right upper paratracheal, bilateral lower paratracheal, left prevascular, precarinal, subcarinal and bilateral hilar minimally increased hypermetabolic lymphadenopathies (SUVmax: 4. 9). - No FDG involvement in the pulmonary parenchyma and abdominopelvic lymph nodes.

q. Histological examination of the endoscopic biopsy specimen demonstrated moderately-differentiated squamous cell carcinoma. q. T 4(? ), N(+), M(-), clinical stage IVA esophageal cancer was diagnosed.

q WHAT WOULD BE YOUR SUGGESTION? A) Neoadjuvant chemotherapy B) Definitive chemoradiation C) Preoperative chemoradiation D) Surgery

• Treated with definitive chemoradiation : 5 -Fluoruracil and Cisplatin and RT to 50. 4 Gy. • Patient is re-evaluated with PET/CT. • PET/CT reported a nearly total improvement in esophageal wall thickening with a total metabolic response and minimally increased FDG uptake in all mediastinal stations suggesting reactive disease. • Thorax CT reported a wall thickening of 8 mm in its thickest place with reversal of esophageal dilatation and multiple mediastinal lymph nodes up to 10 mm diameter.

q WHAT WOULD BE YOUR SUGGESTION? A) Surveillance B) Surgery C) Palliative management D) Chemotherapy

• Total esophagectomy + left thoracotomy + witzell jejunostomy (16. 11. 2017): I. Total esophagectomy + subtotal gastrectomy material - Connective tissue development, frequent coagulation necrosis areas - 1 lymph node: carcinoma metastasis - 9 lymph nodes: reactive hyperplasia II. Subcarinal lymph node: anthracosis, granulomas III. İnferior ligament biopsy: histiocytosis, anthracosis, granulomas No tumors seen at surgical borders.

There were no residual disease in the postoperative CTs.

• Capecitabine and oxaliplatin - Capecitabine 1000 mg/m 2 PO BID on Days 1– 14 - Oxaliplatin 130 mg/m 2 IV on Day 1 - Cycled every 21 days • After 6 cycles of adjuvant chemotherapy, patient is re-evaluated with a PET/CT which showed no FDG uptake ( 04. 05. 2018 ) • There was no pathological lesion in Thorax CTs (04. 11. 2018).

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Case Presentation -2 q 79 -year-old q♂ q 2 children q ECOG PS 2 q GERD , COPD, CAD q Persistent dysphagia

• Esophagography (2007): marked dilatation of the esophagus, to about 2 cm in diameter, proximal to the gastroesophageal junction, which was diagnosed as achalasia of the esophagus. • Endoscopic balloon dilatation was performed three times from May 2007 to 2015.

• In September 2015, routine follow-up upper GI endoscopy revealed a shallow depressed lesion(0 -IIc) in the proximal esophagus located 25 cm from the incisors. • The biopsy findings indicated moderately differentiated squamous cell carcinoma. • Endoscopic ultrasound (EUS) was performed and revealed a blurring and thickening of the third layer (submucosal layer) but not fourth layer. • There were no lymph nodes seen. • No metastases on a computed tomography (CT) scan or a positron emission tomography (PET)-CT scan.

• ESD was made difficult by bleeding from abundant microvessels in the submucosal layer. • The lesion was excised and pathological findings revealed partial thickening of the mucosa and squamous cell carcinoma (0 -IIc, 41 x 57 mm, depth T 1 a-EP(M 1), ly 0, v 0, p. HM 0, p. VN 0).

• In May 2017, routine follow-up upper GI endoscopy again showed a shallow depressed lesion (0 -IIc) in the upper esophagus. • An ESD is performed again. • The pathological examination revealed squamous cell carcinoma (0 IIc, 21 x 13 mm, depth T 1 b(SM 2), ly 0, v 2, p. HM 0, p. VM 0). • Patient refused surgery.

q WHAT WOULD BE YOUR SUGGESTION? A) Surveillance B) Surgery C) Definitive chemoradiation

• Treated with definitive chemoradiation : Capecitabine and oxaliplatin and RT to 50. 4 Gy. - Oxaliplatin 85 mg/m 2 IV on Days 1, 15, and 29 for 3 doses - Capecitabine 625 mg/m 2 PO BID on Days 1– 5 weekly for 5 weeks. • There were no pathological lesions in follow-up imagings. • Since then, the patient has had no recurrence.

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