CASE STUDY:

SYNCHRONOUS LUNG AND

ESOPHAGEAL CANCER
JOSH BARRUS
 • 66 years old
• Male
• White
PATIENT
• Treated at Riverside Methodist Hospital (Trilogy)
DEMOGRAPHICS • Diagnosed with synchronous Stage IIB squamous cell carcinoma
of the right upper lobe and Stage I esophageal adenocarcinoma
 MEDICAL & SOCIAL HISTORY
• Diabetes Mellitus
• Hypertension
• Surgical History
• Tonsillectomy
• Esophagogastroduodenoscopy (8/1)
• No spouse or children
• Former smoker (pack-years not specified)
• Denies any alcohol or drug use ever
HISTORY OF PRESENT ILLNESS
• Late July—Presented to ED with change in mental status
• Found to be hypoglycemic
• Blood panel indicated elevated creatinine
• July 30—CT of abdomen and pelvis
• Found significant cirrhosis of liver, ascites, body wall edema, mild bilateral pleural effusion
• Paracentesis was performed to remove 24.8 L of fluid from abdominal cavity
• August 1—Bright red blood in rectum
• Endoscopy of upper GI tract was performed
• Grade 3 varices found in upper 1/3 of esophagus (enlarged blood vessels associated with liver damage)
• Barrett esophagus
• Medium-sized ulcerating mass in middle 1/3 of esophagus
• Biopsy positive for adenocarcinoma
HISTORY OF PRESENT ILLNESS

• August 7—CT of chest, abdomen, and pelvis

• Found large, spiculated lung mass in RUL, abutting mediastinum (6.6cm x 5.5cm x 5.5cm)
• Biopsy taken using endobrachial ultrasound—positive for squamous cell carcinoma

• Involvement of upper and lower right paratracheal lymph nodes

• One small paraesophageal lymph node involved
• August 19—PET scan
• Showed hypermetabolic mass in RUL and esophagus
• No further mediastinal or hilar node involvement besides those listed above
EPIDEMIOLOGY—LUNG

• Lung tumors are among the most common malignancies in the world
• Represent approximately 15% of all cancers in the U.S. and 29% of cancer deaths
• Lung cancer incidence is closely related to rates of cigarette smoking
• Heavy smoking has declined throughout the last century, but light smokers have increased from 16% to 22% of the
population
• Since 1950, the male to female smoking ratio has changed from 6:1 to nearly 1:1
• Lung cancer has become the leading cause of cancer-related death in women, over breast cancer
• Disparities in smoking rate based on race, ethnicity, and level of education are still significant
• The rate of high school students who smoke tobacco has decreased from 36% to 18% from 1997-2011
EPIDEMIOLOGY—ESOPHAGUS Bonus question: What type of bird likes to
eat the most?

• Esophageal cancers account for 1% of all

cancers in the U.S.
• Men have 3-4x higher incidence than women
• Highest incidence occurs between 55 and 85
years old
• Increased incidence in northern China, Iran, and
South Africa due to diet-related risk factors
An esopha-goose!!
• Patients often diagnosed at a later stage
ETIOLOGY-LUNG

• Significant tobacco exposure is the most common cause of

lung cancer
• Effects of smoking are increased by
• Duration of smoking
• Use of unfiltered cigarettes
• Total number of cigarettes used
• 87% of lung cancer deaths are caused by smoking tobacco
• Exposure to fumes from coal, tar, nickel, chromium and
arsenic are linked with higher incidence
• Radon and uranium exposure
ETIOLOGY—ESOPHAGUS

• Most common factors include excessive tobacco and alcohol use

• Damage mucosal surfaces
• Both increase risk of developing squamous cell carcinoma
• Tobacco use increases risk of adenocarcinoma
• Barrett esophagus
• Causes normal stratified squamous epithelium to be replaced by
columnar epithelium (more like lining of the stomach)
• Also associated with Gastroesophageal Reflux Disease (GERD)
• Repeated contact with stomach acid may damage cells in lower esophagus
• Diet low in fruits and vegetables, high in nitrates
• Cured and pickled foods
• Obesity also puts patients at higher risk
SIGNS & SYMPTOMS

• Weight loss • Food sticking in throat

• Cough • Regurgitating undigested
• Hemoptysis food
• Dyspnea • Odynophagia (50% of pts.)
• Chest pain • Burning sensation in chest
• SVC Syndrome • Vomiting/coughing blood
• Hoarseness • Horner syndrome
• Arm/shoulder pain • Dysphagia
 • CT scans of chest, abdomen, and pelvis
• Endoscopy of upper GI tract with endoscopic ultrasound
DIAGNOSTIC • Biopsy of tissue taken during endoscopy
STUDIES • PET to determine extent of disease and look for metastasis
• Lung biopsy taken using endobrachial ultrasound
LUNG ANATOMY
LUNG ANATOMY

• Terminal bronchioles lead to air

sacs called alveoli
• These sacs are highly vascularized
for efficient gas exchange
• Pulmonary arteries will bring
deoxygenated blood and acquire
oxygen for transport to the heart
via pulmonary veins
ESOPHAGUS ANATOMY
• Flat, muscular tube posterior to the trachea
• Moves food through coordinated ‘wave’ of
muscular contractions known as peristalsis
• Generally divided into 3 or 4 sections
• Cervical
• Upper thoracic
• Mid-thoracic
• Lower thoracic
• Sometimes split into upper, middle, and
lower 1/3
• Most distal end may be below the diaphragm in
the abdomen
• Constriction of esophagus at
gastroesophageal junction normally prevents
stomach contents from moving superiorly
back through the esophagus
LYMPH NODES
HISTOPATHOLOGY
• Lung cancers are divided into small cell and non-small cell lung cancers
• Non-small cell lung cancer makes up majority of lung cancers
• Made up of several different histologies
• Most commonly adenocarcinoma or squamous cell
carcinoma
• Large cell and adenosquamous carcinomas also fall into
this category
• 30% of primary lung tumors are squamous cell carcinoma
• Adenocarcinoma and large cell are more likely to
metastasize
• Small cell carcinomas less common but highly likely to
metastasize
• Often will treat brain prophylactically under assumption of
micrometastases
HISTOPATHOLOGY—ESOPHAGUS

• Most esophageal tumors (60-80%) are adenocarcinomas

• These tend to occur in the distal portion
• Adenocarcinomas arise more often from GERD, Barrett esophagus, and obesity
• Also increased incidence of adenocarcinomas among white men
• Most other lesions are squamous cell carcinomas
• More commonly seen in the upper and middle esophagus
• Tobacco, alcohol, and poor diet are more closely associated with SCC
• History of H&N cancer also increases risk for SCC
STAGING—LUNG (NSCLC)

Stage I Stage II Stage III Stage IV

• Invasion into • Involving • Extension into • Distant

lung tissue with neighboring other areas of metastasis
no lymph node lymph nodes or the chest, (bone, liver,
involvement invasion into pleura, or brain)
chest wall supraclavicular
nodes
STAGING—ESOPHAGUS (ADENO)

Stage I Stage II Stage III Stage IV

• Small tumor • Tumor invading • Medium-to- • Any size or

invading tissue muscular layer large tumor with nodal
with no regional and/or with 1-2 up to 6 regional involvement
lymph node regional nodes lymph nodes with distant
involvement involved involved metastasis
ROUTES OF METASTASIS—LUNG

• Direct extension
• May spread to other parts of the lung, ribs, heart, esophagus, and vertebrae
• Chest wall, pleura, and pericardium may become involved with non-encapsulated tumors
• Regional lymphatic spread
• May grow and spread between adjacent lymph nodes
• Hematogenous spread
• More often distant metastasis through blood due to highly vascularized lung tissue
• Many blood and lymph vessels converge into the left subclavian vein, giving the tumor quick access to all
parts of the body
• Most common distant metastasis found in cervical lymph nodes, liver, brain, bones, adrenal glands,
kidneys, and contralateral lung
ROUTES OF METASTASIS—ESOPHAGUS

• Often, esophageal tumors grow to a large size before they metastasize

• Nodal spread often occurs along length of the esophagus and trachea
• Skip lesions may be found among these interconnected lymph channels
• Direct invasion
• Esophagus has no serosa layer—tumors can easily grow outside of esophageal tissue into adjacent structures
• Distant metastasis
• Most common sites include liver and lung
• Often via paraesophageal nodes and thoracic duct drainage into left subclavian a.
CHEMOTHERAPY

• Lung
• Used in conjunction with radiation for stage II and III lesions
• Used as stand-alone treatment in stage IV
• Most commonly cisplatin
• Paclitaxel, docetaxel, vinorelbine, gemcitabine, and others show moderate responses as single-agent therapies
• Cisplatin and etoposide may be used with or without radiation to treat extensive disease
• Esophagus
• 5-FU and cisplatin are the most common drugs used in conjunction with radiation
• Paclitaxel with carboplatin or 5-FU with oxaliplatin may also be used
• Patient was not considered a good candidate for chemotherapy due to poor liver function
SURGERY

• Lung
• Surgery more common for stage I and II tumors
• Lobectomy and lymph node dissection in mediastinum
• Esophagus
• Surgery is common for early stage, resectable tumors
• More extensive lesions treated with chemo/radiation
• Determined that patient was a poor candidate for surgery
 • PTV Esophagus: 3750 cGy in 15 fx (250 cGy/fx)
• PTV Lung: 4500 cGy in 15 fx (300 cGy/fx)
• 6 field static IMRT
• 6 MV photons
• No boost
TREATMENT PLAN • Imaged using daily MV-kV and weekly CBCT, aligned to
spine/bony anatomy
• After evaluation by medical and surgical oncology, it was decided
to treat with radiation alone
• Radiation Oncologist suspected that tumor control is unlikely with
radiation alone
POSITIONING AND
IMMOBILIZATION

• Supine
• Wing board with T-grip
• Arms overhead in upper vac bag
• Large knee sponge
• 4D scan used for simulation
• Oral contrast
PLAN PARAMETERS
ORGANS AT RISK

Structure Tolerance Dose (cGy)

Spinal Cord 4700

Heart 4000
Liver 3000
Stomach 5000
Esophagus 5500
Lung 1750
SIDE EFFECTS & MANAGEMENT—LUNG

• Cough
• Esophagitis—magic mouthash
• Skin reaction—Aquaphor, lotions
• Pneumonitis—Oxygen or corticosteroids in more extreme cases
• Pulmonary fibrosis
• Pericarditis
• Brachial plexopathy
• Lhermitte’s Syndrome
• ‘Electric shock’ feeling running down back, arms, and legs
• Due to nerve damage
SIDE EFFECTS & MANAGEMENT—ESOPHAGUS

• Esophagitis, dysphagia, odynophagia

• Eat small, frequent meals
• Diet of soft, bland, pureed foods
• Magic mouthwash
• In more severe cases, NG tube may be necessary
• Nausea and vomiting
• Compazine, Zofran, etc.
• Radiation Pneumonitis
• Esophageal stricture or stenosis
• Swallow foods or liquids regularly throughout treatment
• Surgery to dilate esophagus may be necessary
PROGNOSIS AND SURVIVAL

• 5-year survival for Stage I lung tumors is very good—range from 68%-82%
• Overall 5-year survival for respiratory tumors ranges from 15-20%
• In addition to staging, weight loss of at least 10%, poor performance status, and age>65 years indicate poor
prognosis
• For esophageal tumors, size is the most important prognostic indicator
• 2-year survival with tumor < 5cm is 19.2%
• More often localized (40-60%)
• 75% of tumors > 5cm developed distant metastasis

• 2-year survival with tumor > 9cm is 1.9%

DIFFICULTIES WITH SETUP/TREATMENT

• Difficulty with mobility

• Ambulatory with walker, but had difficulty moving himself around on the table
• Early in treatment, distended abdomen caused positioning difficulties
• Abdomen tended to fall inconsistently to one side or another based on rolling/how the patient laid down
• Often had to hold abdomen in place while rolling to keep fluid from moving around
• Paracentesis performed in the middle of treatment to drain over 14 L of fluid from abdomen
• Skin became loose, SSD’s were changed, all tattoos and marks became unstable and unreliable
• Aligned patient in the area of tattoos and set the table vert
• Relied on imaging to ensure he was positioned correctly
• Back pain made patient very slow to lay down and sit up
• Pain due to weight carried in front of abdomen
 PATIENT PERSPECTIVE
• Overwhelmed by how quickly his diagnoses came
• Went from just managing diabetes and blood pressure to multiple cancer diagnoses and a fluid-filled abdomen in
just a few weeks
• Little family support
• Had a nurse/caregiver that brought him to most treatments
• Having feelings of depression
• Sense of humor
• Spoke of his situation and treatments in a matter-of-fact way
• Did not want to draw attention or pity, but was not outwardly cheerful
• Always kind and appreciative of his care team
REFERENCES
1. Washington CM, Leaver DT. Principles and Practice of Radiation Therapy. 4th ed. St. Louis, MO: Elsevier
Mosby; 2016.
2. Griffin, H. Lung CA. Lecture presented at: The Ohio State University; November 26, 2019; Columbus,
OH.
3. Hackworth, R. Digestive System. Lecture presented at: The Ohio State University; January 22, 2020;
Columbus, OH.
4. Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic irradiation. International
Journal of Radiation Oncology*Biology*Physics. 1991;21(1):109-122. doi:10.1016/0360-
3016(91)90171-y.
Thank You!

Questions?