Initial Considerations Staging

The initial overview of a patient with EC is a multidisci-plinary effort that addresses a number of factors, including tumor histology, staging, and overall health status. An experienced team approach will enable choice of appropriate treatment. The team should include the following:

1. A medical oncologist

2. A radiation oncologist

3. A thoracic surgeon skilled at esophagectomy

4. A gastroenterologist with experience performing endoscopic ultrasound (EUS)

5. A nutrionist familiar with parenteral nutrition

6. Nurses, intensivists and anesthesiologists skilled at caring for these complex patients

Familiarity with these procedures and patients is critical— several studies demonstrate that outcome correlates with surgical volume, expertise of the ultrasonographer, and adequacy of nutritional support (Nozoe et al, 2002; Schlick et al, 1999; Dimick et al, 2003).

perhaps the single most important factor in the evaluation is staging. it determines whether the patient will be treated with curative or palliative intent. Because tissue is obtained most often by endoscopic biopsy, new referrals will have a general description of the endoluminal tumor, including appearance, location within the esophagus (cervical, mid, distal, gastroesophageal junction [GEJ]), and extent of luminal obstruction. Following biopsy confirmation, EUS is now the standard modality for determining T and local N stage, the factors most highly correlated with prognosis in patients with locally advanced disease.

For the primary tumor, EUS provides reliable information about the extent of tumor penetration into, and possibly through, the esophageal wall. Depth of penetration, defined as T stage, correlates with both the extent of lymph node involvement as well as resectability. This directly impacts treatment and prognosis—T4 lesions that invade adjacent structures such as the aorta, vena cava or pericardium are unresectable—and lymph node status correlates with survival. Supplementing information about tumor depth is the ability to image local (periesophageal and celiac) lymph nodes, with the added benefit of endoscopic biopsy if desired for confirmation. For lesions in the distal esophagus or involving the GEJ, EUS also provides information about extension of tumor into the gastric cardia and celiac lymph nodes. Retroflexing the endoscope to detect tumors that emanate primarily from the cardia is essential. In this situation, biopsy of the fundus is important, because these lesions that extend into the body of the stomach are treated as primary gastric tumors. Involvement of celiac nodes (Mia) in disease that straddles the GEJ is still considered locally advanced and thus curable EC. There is an earlier chapter (see Chapter 5, "Endoscopic Ultrasound and Fine Needle Aspiration") on endoscopic ultrasound and fine needle aspiration.

Computed Tomography and Positron Emission Tomography Scans

Computed tomography (CT) and positron emission tomography (PET) are then used to assess for distant metastases (M stage). Until the advent of routinely available PET, CT was the imaging approach of choice for detecting distant lymph nodes and solid organ metastases. CT is still used to stage every patient and to follow each patient for response to therapy. Recent studies by Flamen and colleagues (2000), however, suggest a powerful role of PET in detecting distant disease that is missed by CT. The current approach is to obtain a PET (or PET/CT) scan on every patient considered for curative therapy. In those with PET-detected lesions not seen on CT, the finding should be confirmed with biopsy or additional imaging before denying potential curative treatment. A small fraction of patients with distal lesions will also have occult peritoneal metastases that are too small for detection on PET. However, because all patients slated for curative therapy undergo jejunostomy tube placement, the peritoneum is visualized directly prior to initiation of treatment.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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