IDENTIFICATION: This is a (XX)-year-old man with an adenocarcinoma of the distal esophagus, not yet fully staged.
HISTORY OF PRESENT ILLNESS: The patient has a history of Barrett’s esophagus. He had a radiofrequency ablation procedure in the past. He had a surveillance endoscopy done and had endoscopy on (XX). There was no obvious evidence of Barrett’s esophagus; however, there was noted to be an esophageal nodule with early central ulceration at 36 cm from the incisor. It is about a cm in size. The GE junction was at 40 cm. Biopsy at 36 cm showed adenocarcinoma. Biopsies were taken at 38 cm and were unremarkable and at 40 cm, which showed some mild inflammation. Biopsies at 35 cm showed no evidence of malignancy. He has had a CT scan done of the abdomen and pelvis earlier in August that showed fatty liver. He had CT scan done of the chest in September, which showed no changes in tiny subpleural nodule.
He has had endoscopic ultrasound done with Dr. (XX) in (XX). He was noted to have a 1.5 to 2 cm area focal nodularity in the lower third of the esophagus. The celiac access appeared normal. The EG junction region appeared normal. Esophageal wall was 2 mm and symmetrical. On withdrawal of the endoscope, there was noted to be a 1.8 cm relatively hypoechoic solid lesion, which appeared to be primarily extended to the esophageal wall with focal invasions through it. There is a single 8 mm lymph node peripheral to the mass and other lymph nodes less than 5 mm. Superficial wall of the esophagus appeared intact except for the apparently extrinsic nodule seen invading through the wall.
He has had medical oncology consultation with Dr. (XX). He has suggested FOLFOX chemotherapy and radiation therapy. He has had surgical consultation with Dr. (XX) as the port placement. He will be having a PET scan done tomorrow at the (XX) Hospital.
PAST MEDICAL HISTORY: Myocardial infarction. He has had a PTCA with stent placement in the past as well, hypertension, diabetes, COPD/sleep apnea, hiatal hernia, diverticulosis, colonoscopy was negative in (XX), elevated cholesterol, arthritis/chronic low back pain, and question of sarcoidosis in the past.
PAST SURGICAL HISTORY: Back surgery x3 and tonsillectomy. He has had lazy eyes since childhood and sinus surgery.
ALLERGIES: NKDA.
MEDICATIONS:
- Aspirin 325 mg daily.
- Soma 325 mg 4 times daily as needed.
- Celebrex 200 mg daily.
- Valium 10 mg every 6 hours as needed.
- Vitamin D2 50,000 units weekly.
- Lasix 40 mg twice daily.
- Neurontin 300 mg 3 times daily.
- Glucovance.
- Lantus insulin, regular insulin.
- Lovaza 2 g twice daily.
- Prilosec 40 mg daily.
- Oxycodone HCL.
- Spironolactone.
- Diovan 160 mg daily.
SOCIAL HISTORY: The patient is seen today with his niece who is very supportive who lives alone in (XX). His sister is also involved in his care. He continues to smoke and has been unsuccessful cutting down. He smoked a pack and a half of cigarettes for over 44 years. He does not drink and occasional marijuana use in the past. He is disabled markedly and has had back problems since (XX). He does not drive. He does not have advanced directives but is interested in filling them out.
FAMILY HISTORY: Father died of esophageal cancer at age 32. 1 sister is alive and well and other is fine. ECOG performance status is 2.
REVIEW OF SYSTEMS: Performed and included in the patient’s radiation oncology department chart.
HEENT: He does note a feeling that his eyes have been somewhat “twitchy” over the past 2 weeks. He does see Dr. (XX) periodically for ophthalmologic followup.
RESPIRATORY: He does have cough.
CONSTITUTIONAL: He has noted perhaps some occasional fevers, not recently.
GI: He does move his bowels every 8-10 days. Nocturia 2-3 times per night.
MUSCULOSKELETAL: He walks with a cane.
GENERAL: The patient is an obese man, who appears his stated age.
VITAL SIGNS: Pulse 86, BP 154/70, weight 179.4 pounds, height 6 feet 4 inches, room air O2 saturation is 95%.
HEENT: Gaze is somewhat disconjugate; however, it does normalize at times as well. Oral cavity is unremarkable.
NECK: Supple.
NODES: No cervical or supraclavicular adenopathy.
LUNGS: Clear. Diminished at the bases.
HEART: Regular.
ABDOMEN: Soft, obese, and nontender. Positive bowel sounds. No organomegaly.
IMPRESSION AND PLAN: The patient is a (XX)-year-old man with an adenocarcinoma arising. It appears at this point in the region of the distal esophagus. Endoscopic ultrasound findings suggest process external to the esophagus extending in. We think it may still be reasonable to treat him for an adenocarcinoma of the distal esophagus/gastroesophageal junction, but we will await discussion with Dr. (XX) and results of his PET scan. He does not appear to have been assigned a stage based on endoscopic ultrasound to date. We did discuss treatment options with the patient and his niece provided that this disease is localized.
Options would include surgical resection versus chemotherapy and radiation therapy. Radiation will generally be treatment in the rage of 5000 to 5400 cGy in 25-28 treatments with current chemotherapy potentially to be followed by surgical resection and 10 of treatment would be curative. We reviewed the planning of daily treatment process, including the use of a planning CT scan. We discussed potential side effects including fatigue, skin erythema, irritation difficulty swallowing and pain in the esophagus, nausea, radiation pneumonitis with cough and shortness of breath and potential for cardiac injury as well as low blood counts with risk of anemia and infection. We have explained that in general he is more able to tolerate the treatment, but there is some chance that his breathing capacity could be diminished somewhat after radiation therapy and also that there could long-term be some cardiac injury. We suspect he will eventually require radiation therapy, but at this point, he is still being staged. Their questions were answered. We will plan to discuss his case further with Dr. (XX).
