Esophagus

G1: Well differentiated (low grade). G2: Moderately differentiated (intermediate grade). G3: Undifferentiated (high grade).[2] || TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ T1 Tumor invades lamina propria or submucosa T2 Tumor invades muscularis propria T3 Tumor invades adventitia T4 Tumor invades adjacent structures NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis MX Distant metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis Tumors of lower thoracic esophagus M1a Metastasis in celiac lymph nodes M1b Other distant metastasis Tumors of upper thoracic esophagus M1a Metastasis in cervical nodes M1b Other distant metastasis **Stage Grouping** Stage 0 Tis N0 M0 Stage I T1 N0 M0  Stage IIA T2 N0 M0  T3 N0 M0  Stage IIB T1 N1 M0  T2 N1 M0  Stage III T3 N1 M0  T4 Any N M0  Stage IVA Any T Any N M1a Stage IVB Any T Any N M1b || This makes the prognosis poor overall.
 * **Epidemiolgy:** || More common in men than women with a higher incidence rate in African Americans than Caucasians. Typically diagnosed in patients over 55 years of age.[1] The 10-25% of cases are in the upper esophagus, 40-50% in the middle esophagus, and 25-50% in the lower esophagus.[2] The highest frequency of diagnosis is in China, Iran and South Africa.[1] ||
 * **Etiology:** || A history of achalasia (a disorder of the esophageal muscles in which smooth muscle can not move food down the esophagus) is associated with the development of squamous cell carcinoma. Alcohol and tobacco use and dietary factors are also risk factors. Barrett’s esophagus is associated with the development of adenocarcinoma of the esophagus.[1,3] ||
 * **Signs & Symptoms:** || The common signs and symptoms are weight-loss, dysphagia, and odynophagia. Locally advanced tumors may cause hematemesis, cough, hemoptysis, or voice hoarseness with nerve involvement.[1,2] ||
 * **Diagnostic Procedures:** || Esophagus carcinomas are commonly diagnosed by upper endoscopy. During this procedure, the physician can also allocate the proximal and distal extent of the tumor and obtain biopsies of the tumor. Computed tomography (CT) imaging studies of the chest and abdomen is always done after the initial diagnosis. The CT helps to identify the extension beyond the esophageal wall, enlarged lymph nodes, and any local metastases. Endoscopy ultra sound (EUS) is often used to determine the depth of invasion as well as lymph node involvement. Currently, a positron emission tomography – computed tomography (PET-CT) is regularly used together with endoscopy and CT as a standard workup in diagnosis. [2,4] ||
 * **Histology:** || The most common histological types of esophageal tumors are squamous and adenocarcinoma. The location of the tumor also has an impact on tumor types. Tumors of upper and middle portion of the esophagus are commonly squamous cell. The tumors of the distal portion of the esophagus are typically adenocarcinomas. The incidences of adenocarcinomas are higher than squamous cell carcinoma. However, there are also other histological types of tumors that arise in the esophagus. [4] ||
 * **Lymph node drainage:** || Tumors of the esophagus are commonly spread by lymphatics. The incidence of lymphatic spread is related to the location of the primary tumor. Abdominal lymph node involvement is often seen with tumors located in the thoracic region of the esophagus. Tumors of cervical esophaguscommonly spread to the cervical lymph nodes. The relationship between the location and metastases is described in figure 1. [4] ||
 * **Metastatic spread:** || The entire esophagus is at risk for metastatic spread. Lymphatic metastasis are very common. Other common sites of metastases include the lung, liver, pleura, bone, kidney and adrenal gland.[2] ||
 * **Grading:** || Tumor Grading for the esophagus.
 * **Staging:** || __TNM staging for cancer of the esophagus__ [2]
 * Primary Tumor (T) **
 * Regional Lymph Nodes (N) **
 * Distant Metastasis (M) **
 * **Radiation side effects:** || Acute complications of radiation therapy include esophagitis, modest skin tanning, fatigue and weight loss. Pneumonitis is a potentially serious complication. The most common chronic complication from radiation therapy is stenosis and stricture formation. [2] ||
 * **Prognosis:** || Esophageal cancer usually manifests itself as an advanced-stage disease.
 * 75% of the patients have diseased lymph nodes at initial presentation.
 * The 5 year survival is only 3%.
 * No nodal involvement-5 Year survival is 42%
 * Around 18% of patients will have distant metastases.
 * The prognosis is poor, with surgical cure in less than 10% of the patients.
 * The upper one-third lesions do better than those in the lower one third.
 * Tumors ≤5cm are 40% resectable
 * Tumors >5cm have a 75% chance of distant metastasis.

Patients who have the worst prognosis: Median survival of patients with resectable tumors is only about 11 months. Overall the 5 year survival rate is less than 5%, but each patient’s prognosis depends largely on their stage. [1] Survival rates for esophagus cancer are grouped in terms of localized, regional, and distant. • In early-stage lesions surgery would be the standard treatment method. • A laparotomy can be performed before, or concurrently with, esophagectomy to rule out any disease below the diaphragm. • Esophagogastrostomy is the most widely used method. • Squamous cell carcinoma of the cervical esophagus presents a very difficult situation. If surgery is performed, it usually requires removal of portions of the pharynx, the entire larynx and thyroid gland, and the proximal esophagus. Radical neck dissections are also carried out. • Irradiation is mainly used for palliation or for medically inoperable patients. • Squamous cell carcinoma of the upper aerodigestive tract treated with 50.4 Gy at 1.8 Gy per fraction over 5 weeks should control more than 90 percent of subclinical disease. • In addition to external-beam therapy, intracavitary therapy can be sued as part of a radical or palliative treatment. • Iridium 192 is the most common technique used for brachytherapy. The catheter is inserted through the nose into the esophagus. The dose used for this technique is 10 to 20 Gy. [5] • Chemotherapy is not effective as a single modality. • The combination of chemotherapy and irradiation suggests a benefit for both local control and overall survival duration that is superior to radiation alone in inoperable disease. • Concurrent chemoirradiation followed by surgery seemed to result in a higher response rate (70%) and pathologic complete response (37%). || Organ 1/3 2/3 Heart 60 45 Pericarditis Kidney 50 30 Clinical nephritis Liver 50 35 Liver failure Cord 50 (5cm) 50 (10 cm) Myelitis/necrosis Lung 45 30 Pneumonitis || [2] Chao KS, Perez CA, Brady LW. //Radiation Oncology Management Decisions//. 2nd ed. Lippincott Williams & Wilkins; 2002. [3]Wikipedia. [] Last modified June 3, 2012. Accessed June 4, 2012. [4] Hoppe TR, Phillips LT, Roach M. Leibel and Phillips Textbook of Radiation Oncology. 3rd Edition. Philadelphia: Saunders, Elsevier. 2010 [5] //Proton Beam Therapy and Concurrent Chemotherapy for Esophageal Cancer.// []. Accessed June 9, 2012. || Figure 1. Lymphatic spread rate. [4] Back to Week 3
 * male
 * older than 65 years of age
 * have poor performance status
 * excessive weight loss
 * Localized means that the cancer is only growing in the esophagus.
 * Regional means that the cancer has spread to nearby lymph nodes or tissues.
 * Distant means that the cancer has spread to organs or lymph nodes away from the esophagus.[2] ||  ||   ||
 * **Treatments:** || Treatment is very difficult for carcinoma of the esophagus.
 * Surgery ** [2]:
 * **Treatments:** || Treatment is very difficult for carcinoma of the esophagus.
 * Surgery ** [2]:
 * Surgery ** [2]:
 * Radiation Therapy ** [2]
 * Chemotherapy ** [2]
 * **TD 5/5:** || Volume (Gy) Volume (Gy) End Point
 * **References:** || [1] Washington CM, Leaver D. //Principles and Practice of Radiation Therapy//. 2nd ed. Mosby; 2004.