Background

2009 衛生署生命統計報告 惡性腫瘤 : 97 年十大主要癌症順位與死亡人數占率 (1) 肺癌 20.0% (2) 肝癌 19.7% (3) 結腸直腸癌 11.0% (4) 女性乳癌 4.0% (5) 胃癌 5.9% (6) 口腔癌 5.7% (7) 攝護腺癌 2.3% (8) 子宮頸癌 1.8% (9) 食道癌 3.7% (10) 胰臟癌 3.5% 97 年前十大主要癌症順位與去年相同

2009 衛生署統計室

我國癌症趨勢 十大癌症年增率比較 ( 標準化死亡率 ) 除子宮頸癌、胃癌、肺癌下降外，餘均上升 食道癌、胰臟癌標準化死亡率年增率均在 2 至 4 ％ 間，增幅較為明顯 肝癌、結腸直腸癌、女性乳癌、與攝護腺癌標準 化死亡率年增率均在 2 ％以下。

我國癌症趨勢 癌症死亡年齡中位數後延 10 年來除食道癌外，癌症死亡年齡中位數 有後延趨勢 97 年國人癌症死亡者平均年齡為 66.7 歲，較 87 年增加 2.4 歲 死亡年齡中位數為 69.0 歲，較 87 年增 2 歲， 其中男性增 2 歲；女性增 3 歲。

2009 衛生署統計室

我國癌症趨勢 癌症死因死亡年齡 十大主要癌症死因中肝癌、女性乳癌、口 腔癌、子宮頸癌、食道癌等 5 類癌症死因死 亡年齡中位數低於所有癌症死亡年齡中位 數 69 歲，而女性乳癌、口腔癌與食道癌死 亡年齡中位數更低於 60 歲。 近 10 年來，各主要癌症死因中死亡年齡中 位數除食道癌下降 8 歲外，其餘各主要癌症 死因之死亡年齡均有增長趨勢。

2003 年全國男性與 歲男性癌症發生率之比較 順位 全國男性 歲男性 原發部位個案數粗發生率原發部位個案數粗發生率 1 肝及肝內膽管 6, 口腔、口咽及下咽 1, 肺、支氣管及氣管 5, 肝及肝內膽管 結腸及直腸 4, 鼻咽 口腔、口咽及下咽 4, 結腸及直腸 胃 2, 肺、支氣管及氣管 攝護腺 2, 食道 膀胱 1, 胃 食道 1, 白血病 鼻咽 1, 皮膚 皮膚 甲狀腺

2009 衛生署統計室

我國癌症趨勢 主要癌症標準化死亡率的變動 10 年來主要癌症的標準化死亡率變動，以子宮頸 癌與胃癌分別減少 52.7% 與 35.3% 最為顯著 肺癌與肝癌雖列居癌症死因順位的前 2 名，但 10 年 來肺癌與肝癌標準化死亡率分別減少 4.7% 與 4.8% 此 4 主要癌症標準化死亡率的減少，是國人整體癌 症標準化死亡率降低的主因 另外， 10 年來口腔癌、食道癌與女性乳癌之標準 化死亡率都是兩位數字的成長，尤其男性口腔癌 成長 49.1% ；女性則以乳癌、肝癌分別成長 12.5% 與 6.8% 較為顯著

Esophageal Cancer Incidence Taiwan male: 7 /100,000 female: 0.6/100,000 CGMH 60 cases annually in Keelung CGMH (include 20 that outside of Keelung)

Staging Workup

TNM Staging System for Esophageal Neoplasms Primary tumor (T) 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 Regional lymph nodes (N) NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastases N1 Regional lymph node metastasis Distant metastasis (M)

Distant Metastasis (M) MX Distant metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis L/3, Tumors of the lower thoracic esophagus: M1a Metastasis in celiac lymph nodes M1b Other distant metastasis M/3, Tumors of the mid thoracic esophagus: M1a Not applicable M1b Nonregional lymph nodes and/or other distant metastasis U/3, Tumors of the upper thoracic esophagus: M1a Metastasis in cervical nodes M1b Other distant metastasis

Stage Grouping Stage 0 Stage I Stage IIA Stage IIB Stage III Stage IV Stage IVA Stage IVB M0 M1 M1a M1b Tis T1 T2 T3 T1 T2 T3 T4 Any T N0 N1 Any N

Histologic Grade (G) GX Grade cannot be assessed G1 Well differentiated G2 Moderately differentiated G3 Poorly differentiated G4 Undifferentiated

Histology: other than grade predicting LN mets in early esophageal ca 1.depth of tumor invasion 2.Microscopic vascular invasion 3.Microscopic lymphatic invasion 4.Neural invasion Aug 2008 Ann Surg Oncol

About lymph node status: N Mid third (M/3)Lower third (L/3)

About lymph node status: N Involvement of more-distant lymph nodes is currently considered distant metastasis (M1a). (e.g. cervical or celiac nodes for intrathoracic tumors) Recent studies suggest: distant LN mets (M1) had a better overall survival than visceral mets (M1), and 10% chance of cure at 5 years after surgical resection. Ever suggested: distant LN mets be classified as N2 rather than M1a but such a change in classification requires further study.

Waiting a new staging system lung cancer as the example

History & PE PES Esophagography * （ optional ） EUS(endoscopic ultrasound) Bronchoscopy * （ tumor above carina ） SMA-12 、 CBC/DC CRP HBsAg 、 AntiHCV Ac Sugar CT scan * （ H&N 、 Chest 、 Abdomen ） Bone scan PETIf no visceral M1b Liver echo * （ if liver disease suspected ） Biopsy * （ proof for suspected metastatic sites if possible ） Pulmonary function test EKG Nutritional counseling ESOPHAGEAL CANCER 2009 KEELUNG CGMH Guideline Workup

Treatment

Local ablation therapy Surgical resection Concurrent chemoradiotherapy (CCRT)

ESOPHAGEAL CANCER 2009 KEELUNG CGMH Guideline Treatment in non-M1b disease Surgery ： 1 、 non-cervical T1 No & T2 No 2 、 could be offered for localized resectable disease 3 、 C/3 (cervical esophageal cancer) is preferred for CCRT 4 、 higher U/3 will put to esophagus panel discussion Endoscopic mucosal resection (EMR) could be offered for stage I limited in mucosa layer induction CCRT followed by surgery 1 、 P.S. ＜ 2 2 、 adequate PFT 3 、 liver cirrhosis Child ’ s classification B or C will be excluded 4 、 T1-4, N0-1, M0-1a 5 、 M1b with possible curetive resection and good performance status will put to panel discussion 6 、 RT cGy 7 、 chemotherapy ： cisplatin/5FU based regimens or clinical trials 8 、 before surgery, repeat （ i ） CT scan （ ii ） PET recommended （ iii ） PES optional primary CCRT: only after panel discussion postop CCRT: given only if no induction CCRT

ESOPHAGEAL CANCER 2009 KEELUNG CGMH Guideline Supportive treatment in M1b disease with visceral metastasis  chemotherapy or best supportive care  palliative RT stent  esophagus dilatation NG, Percutaneous gastrostomy (PEG) or feeding jejunostomy

Endoscopic Mucosal Resection (EMR) in Tis & T1a 132 (74%) were in the endoscopic endoscopic (ENDO*) group and 46 (26%) were in the surgical (SURG) group. Treatment modality was not a significant predictor of survival on multivariable analysis. Recurrence in 12% of patients in the ENDO group, all successfully re-treated endoscopically without impact on overall survival. Overall survival in mucosal (T1a) EAC in ENDO: comparable with SURG group ENDO*: EMR or EMR + PhotoDynamic Tx Endoscopic and Surgical Treatment of Mucosal (T1a) Esophageal Adenocarcinoma in Barrett's Esophagus. Prasad et al. Gastroenterology 2009;137:

For most patients who have locally advanced esophageal cancer Primary CCRT CCRT followed by surgery

Treatment Timetable wk chemo CCC RT RTRT RTRT RTRT RTRT RTRT RTRT OP Op ←← CT, EUSCT PET

Radiotherapy Surgery

Role of CT Scan CT is inaccurate in determining T stage, because it cannot define individual layers of the esophageal wall and will miss small T1 and T2 tumors. CT assessment of LNs (regional or distant) is limited by relatively low sensitivity (50% to 70%) due to its reliance on size criteria (larger than 1 cm) alone. accuracy in determining lymph node involvement is limited (approximately 60%). Because lymph node involvement is frequently seen in small or normal-size lymph nodes, the false-negative rate is high, and despite a reasonable specificity of 85%,

Role of PET The accuracy of FDG-PET in assessing regional lymph nodes : between the low and high accuracy of CT and EUS, respectively FDG-PET is superior to CT, with a sensitivity, specificity, and accuracy all in the range of 80% to 90%, in detection of distant metastases, as numerous studies confirm This translates into the detection of unsuspected metastatic disease up-staging in 15% of patients and; down-staging in 10%, which leads to alteration of the intended treatment plan in at least 20% of patients. FDG-PET appears to have some value in evaluating response to chemotherapy and radiotherapy

An analysis of multiple staging management strategies for carcinoma of the esophagus: computed tomography, endoscopic ultrasound, positron emission tomography, and thoracoscopy/laparoscopy comparing the health care costs and efficacy of staging procedures including CT scan, EUS FNA, PET, and thoracoscopy-laparoscopy reported : CT plus EUS FNA was the least expensive and offered the most quality-adjusted life-years on average than all the other strategies. PET plus EUS FNA was somewhat more effective but also more expensive Wallace MB, Nietert PJ, Earle C, et al.. Ann Thorac Surg 2002;74:1026.