Esophageal Cancer

1. Please Open the Example Paper, review how it is written. This assignment should be like this example paper, but write down each point above the each paragraph. Like this:

 

Epidemiology

Then go on and start writing about this topic until you move on to the next bullet.

 

This paper is on Esophagus Adenocarcinoma Distal Segment (the part that connects to the stomach). It’s in the Cancer TNM stage of T2N2M0, which I also wrote down in the outline of to what it means. You can also look it up for more clarity.

 

 

2. Follow the Outline I have attached:

Some parts to the outline I have already wrote what needs to be talked about but do add more if needed. If left blank please find it. I have also attached PDF files and PPT’s you should use to complete this assignment. Please look at them all, everything should be there if not use online sources and reference correctly.

 

The PDF with the name Chapter 50 Esophageal Cancer should have all the information you need.

 

4. Please e-mail if you have any questions and I’m required to have 7 pages, thank you.

NSCLC T1N0M0 Left Lower Lobe 1

 

Lung cancer is the leading cause of cancer related deaths in both male and females. Approximately 10% of patients with lunch cancer will survive five years after diagnosis (Portal Design in Radiation Therapy). According to the American Cancer Society, approximately 170,000 new cases are diagnosed and approximately 157,000 deaths are caused by the disease each year (Greenlee RT, Hill-Harmon MB, 2001). Age and gender have the most dominant effect on the epidemiology of this disease. Men have a higher incidence than women, although the mortality rates have significantly increased for women over the past half century. The average age for onset is 60 years old.

The most common cause of lung cancer is significant tobacco exposure. Smoking contributes to 80%-90% of lung cancer deaths in women and men, respectively. Men who smoke are 23 times more likely to develop lung cancer and women are 13 times more likely, compared to never smokers (U.S. Department of Health and Human Services, 2004). Between 2005 and 2010, an average of 130,659 Americans (74,300 men and 56,359 women) died of smoking-attributable lung cancer each year. Exposure to secondhand smoke causes approximately 7,330 lung cancer deaths among nonsmokers every year (U.S. Department of Health and Human Services, 2014).

Exposure to radon is estimated to be the second leading cause of lung cancer, accounting for an estimated 21,000 lung cancer deaths each year. Radon is a tasteless, colorless and odorless gas that is produced by decaying uranium and occurs naturally in soil and rock. The majority of these deaths occur among smokers since there is a greater risk for lung cancer when smokers are also exposed to radon (U.S. Environmental Protection Agency, 2013). Aside from excessive tobacco usage and exposure to radon, additional causative factors include exposure to combustion by-products, asbestos, pollution, pitchblende, chemicals, metals and ionizing radiation.

Smoking cessation as well as preventing nonsmokers from being exposed to tobacco smoke is the most efficient way to prevent stage 1A NSCLC (American Cancer Society, 2014). LDCT, low-dose computed tomography, is currently the only recommended screening test for lung cancers and successfully shows high sensitivity and acceptable specificity for the detection of lung cancer in high-risk people. Chest radiographs as well as cytologic evaluation can present suspicion for lung cancer; however, they cannot be used as definitive screening modalities because they have not shown adequate sensitivity or specificity as screening tests. According to the Principles and Practices of Radiation Therapy, the CT to the chest evaluates the primary finding itself, the possibility of other pulmonary lesions, the involvement of mediastinal and paramediastinal structures and pleural or extrapleural thoracic involvement.

The left lobe of the lung is divided into two sections: the upper lobe and the lower lobe. The right and left lobes of the lung are separated in the midline by the mediastinum which is composed of the heart, thymus, trachea, great vessels, esophagus and lymph nodes. The hilum of the lung is the area in which the blood, lymphatic vessels and nerves enter and exit each lung.

The lymphatic system is important in lung cancer because it is one of the principle routes of regional spread. There are two ways cancer cells can detach from the tumor mass and enter the lymphatics. Detached tumor cells can either undergo regional extension, which is where the cells get trapped in the nodes as the lymphatic fluid is filtered, then the cells continue to colonize in the nodes and eventually pass from one node to the next, or detached tumor cells may grow through the lymph node and gain access to the circulatory system through the blood vessels supplying the node.

Tolerance Doses for Dose Limiting Structures
Organ	Injury	TD 5/5 (cGy)
Heart	Pericarditis Condition in which the sac-like covering around the heart (pericardium) becomes inflamed.	4000
Lungs	Pneumonitis Inflammation of the lung tissue	1750
Esophagus	Clinical Stricture/ Perforation Piercing	5500
Spinal Cord	Myelitis/Necrosis Myelitis involves the infection or the inflammation of the white matter or gray matter of the spinal cord	4500

According to our text, involvement of the lymphatics tends to occur early and follows the divisions of the bronchial tree. The intrapulmonary nodes along the segmental bronchi are initially involved, followed by spread to the hilar nodes. The lymphatic channels then drain to the mediastinal nodes (paratracheal, subcarinal, interalobal, paraesophageal, and upper aortic) and ultimately to the supraclavicular nodes and are considered regional drainage. In some cases, regional spread may be to the adjacent lobe which would be considered metastatic spread. In lung cancer, blood metastases are common to the liver, brain, bone and bone marrow and small cell cancer has a high risk for brain metastasis early on. In stage 1A NSCLC, however, there is no regional lymph node involvement and no metastasis of the disease.

 

The natural history, or the progression of stage IA NSCLC over time in the absence of treatment, was examined in the largest study of untreated stage I NSCLC reported to date. In this study, a total of 19,702 patients had stage I NSCLC, of whom, 1,432 did not have surgery, chemotherapy or radiation treatments. Of these patients, only 42 were alive 5 years after their initial diagnosis. Results from the study indicated that five-year overall survival for untreated stage I NSCLC was 6% overall, among these untreated patients, the median survival was 9 months overall. Conclusive evidence from the study suggests that long term survival with untreated stage I NSCLC is uncommon and the vast majority of patients die of lung cancer, therefore, surgical resection or other treatments should not be delayed for patients diagnosed with stage I NSCLC. (Dr. Raz, Zell, Ou, Gandara, Jablons, 2007).

Signs and symptoms at the clinical presentation of lung cancer often include a history of smoking, a persistent and unproductive cough, hoarseness, hemoptysis, weight loss, dyspnea, unresolved pneumonitis, chest wall pain, atelectasis, pleural effusion and weakness in arm or swelling in neck for apical lung tumors. Lung cancer, however, often produces no symptoms until the disease is well advanced. For stage IA NSCLC, according to the Principles and Practices of Radiation Therapy, approximately 75% of patients experience a cough with 60% of patients experiencing hemoptysis, blood associated with the cough upon clinical presentation. Approximately 15% of patients complain of a recent onset of dyspnea and a similar percentage exhibit chest pain.

The workup for the detection and diagnosis of lung cancer initially consists of obtaining the patients history and a physical examination of the patient with a chest x-ray. CT chest exanimations of the thorax and abdomen using PA and lateral projections are used for the detection of lung cancer. The process of diagnosis includes acquisition of anatomical imaging and a biopsy. CT examinations are often crucial in selecting sites for a biopsy. MRI and PET imaging modalities are also used in the detection and diagnosis of NSCLC. MRI reveals invasion evidence of a tumor into the chest wall, diaphragm, or other areas and the PET CT which provides a clearer picture of what type of cells might be growing via visualization of metabolic activity.

Tumor markers such as ALK gene rearrangements and EGFR mutation analysis are examined via analyzing the tumor tissue from biopsy to help determine treatment and prognosis of NSCLC. Alpha-fetoprotein (AFP) is another tumor marker utilized by analyzing blood which aids in monitoring to recurrence. Pulmonary function laboratory tests and studies measure how well the lungs take in and release air. Pulmonary function studies are beneficial primarily for determining a patient’s ability to withstand various types of treatment.

Surgical tests to diagnose NSCLC include sputum cytology, thoracentesis, fine needle aspiration biopsy and bronchoscopy. Tumor histology is most frequently obtained through a fiberoptic bronchoscopy because up to 75% of lesions may be visible in this fashion. Bronchoscopies are used to help the doctor find tumors or blockages in the larger airways of the lungs which are then biopsied during the procedure. During the procedure, the flexible bronchoscope is passed through the nose or mouth down into the windpipe and bronchi. Small instruments are placed down the bronchoscope to take samples of these tissues which are then examined under the microscope (American Cancer Society, 2015). The tissue taken from the biopsy is then sent to the pathology laboratory and examined by a pathologist.

NSCLC histologies are often classified together although they are heterogeneous in nature. The most common histologies include epidermoid or squamous cell carcinoma, adenocarcinoma and large cell carcinoma. The reason behind the combination of these heterogeneous histologies is due to the similar approach in diagnosis, staging, prognosis and treatment and because they act in a similar fashion clinically overall.

NSCLC T1N0M0 is grouped as a stage 1A non-small cell lung cancer. The TNM staging system reveals that the primary tumor is 3cm or less, and it has not extended into the membranes surrounding the lungs. The primary tumor staging also reveals that the tumor is surrounded by lung or visceral pleura, and the tumor lacks bronchoscopic evidence of invasion more proximal to the lobar bronchus. The regional lymph node status indicates no regional lymph node metastasis and the distant metastasis staging indicates no distant metastasis. No grading system is used to classify this disease.

Multiple modalities used in the treatment of stage 1A NSCLC include surgery, radiation therapy and adjuvant chemotherapy. Prior to treatment, the patient’s performance must be evaluated using the Karnofsky scale. Whenever possible, surgery is recommended as the first treatment route with lobectomy or segmentectomy depending on the size and position of the tumor in the chest.

Radiation therapy is at times utilized prior to surgery to reduce the size of the tumor before the operation or definitively by patients who are not good candidates for surgery. Radiation therapy may also be ideal after surgery for patients with positive margins at the site of resection and for patients who are high risk for locoregional recurrence. Radiation is also used in palliative care to elevate symptoms. Radiation therapy can be used alone or in combination with chemotherapy. Adjuvant chemotherapy is typically given postoperatively to slow or stop the growth of the cancer cells which decreases the risk of relapse of the disease. (Up to Date, 2014).

Common acute side effects of radiation therapy include dermatitis, erythema and esophagitis. Chronic side effects usually occur as a result of doses that exceed organ tolerances and generally include a nonproductive cough, fibrosis of the lung and subcutaneous fibrosis of the skin. According to the American Cancer Society as of 2015 the 5-year observed survival rate for patients who undergo active treatment for stage 1A LLL NSCLC is 49%.

During simulation, the radiation treatment field borders should include the lesion and margin as well as regional lymph nodes. For lower lobe lesions, the treatment borders should include the primary tumor and the entire mediastinum. According to our text, advanced internal volume localization such as breath holds, respiratory gating, and CT simulation at full inspiration and full expiration are helpful in planning. Because critical organs in the thorax have low tolerance doses and varying tissue densities, complex strategies such as oblique off-cord treatments with modifiers such as wedges or tissue compensators or unequal beam weighing techniques might be utilized. Small, localized lesions may be treated with dynamic therapy such as IMRT, stereotactic or tomotherapy.

The patient should be positioned to accommodate a complex treatment plan with their arms raised above the head with the support of appropriate immobilization devices. According to our text, prone positioning for lower lobe lesions can facilitate easy daily setup for off-cord and boost fields. I have never seen a lung cancer patient treated in the prone position before. Immobilization devices might include vaclok, wing boards, a prone pillow support, SBRT full body vaclok for full body immobilization etc.

Total dose to a lung lesion and margin are typically treated to 50Gy with a beam energy of between 10-12MV if radiation is adjuvant to surgery or chemotherapy. Total dose to the lung is typically 45Gy for palliative treatment and 60Gy if radiation is being used alone. Positive lymph nodes should receive maximum of the total dose when possible and negative lymph nodes should receive 45Gy. Conventional fractionation delivers a daily dose of 180cGy to the total dose over a period of 30-34 days.