SESAP Critique

Category 2, Items 17 and 18

Adenocarcinoma of the esophagus seems to be increasing in incidence and represents a formidable surgical challenge. After securing a diagnosis, the next step prior to any definitive oncologic treatment must be a metastatic evaluation, which would include computed tomographic (CT) scan of the chest. This is best performed with oral and intravenous contrast to evaluate for pulmonary metastases and to assess the extent of the invasion (if any) into neighboring structures. Hepatic and renal evaluation are also required for the initial evaluation. CT scan of the head or bone scans are obtained only if symptoms or laboratory findings warrant.

Although alcohol and tobacco use and lye exposure predispose to squamous carcinomas of the esophagus, the prinicpal risk factor in this patient is gastroesophageal reflux disease. This is supported by the finding of Barrett’s esophagitis.

Chest CT showed an advanced lesion in this case, and the patient was treated with a preoperative regimen of cisplatinum and fluorouracil (5-FU), delivered concomitantly with external-beam radiation therapy. The time line shows how they were delivered (45 Gy) over 35 days. This is followed by a three- to six-week rest and reevaluation prior to any surgical resection.

In a recent prospective randomized trial, this preoperative regimen increased survival significantly when compared with operation alone. Long-term survival of patients who have complete resection after this preoperative regimen may be significantly increased compared with patients who were treated with single modality therpay. Progression of the tumor despite chemoradiotherapy is unusual, but such patients are usually not candidates for resection. However, patients responding to treatment should be considered for resection.