Patient diagnosis and history:
A 41-year-old man presented with a locally advanced esophageal cancer. He was treated with neoadjuvant chemo-radiotherapy, surgery, and then additional adjuvant chemotherapy.
The patient did well for nearly five years when he presented with an enlarged left supraclavicular lymph node. He underwent a left-modified radical neck dissection. Four of 25 lymph nodes were involved with malignancy that was consistent with recurrent esophageal cancer. The largest deposit measured 5cm. There was also evidence of extracapsular extension. A complete staging evaluation revealed no evidence of disease elsewhere. He subsequently received radiotherapy to the left neck and supraclavicular fossa. He also received adjuvant chemotherapy.
Within a few months, the patient developed bone metastasis and received additional palliative radiation therapy and chemotherapy.
The patient then was noted to have a new 8 x 10mm nodule located along the anterior margin of the thoracic esophagus that was metabolically active on PET-CT. The patient underwent an esophageal endoscopic ultrasound and FNA. Pathology revealed malignant cells consistent with adenocarcinoma. This lesion appeared to originate between the superior edge of the initial radiation therapy fields and the inferior edge of the more recent supraclavicular radiation therapy fields. On the CT PET there was evidence of a hypermetabolic lesion in the liver and in the L2 vertebral body. The patient was treated with chemotherapy. Unfortunately, the disease progressed and the patient became symptomatic with hoarseness. Despite his disease, the patient had been functional throughout this time and the hoarseness/loss of voice had a dramatic impact on his quality of life.
The patient subsequently underwent radiation treatment to this isolated focus of disease in close proximity to the two previously treated fields utilizing Elekta Synergy® image guided system with VolumeViewTM imaging software.
Vivek Mehta MD
Tony Wong, Jin-song Ye
Lead Radiation Therapist: